17. ODD? A newly described behavior disorder

By Tom O'Connell

We've had LD (Learning Disabled) and ADHD (Attention Deficit Hyperactivity Disorder) with us for a while. Now there is a more recently identified disorder known as ODD, which means "Oppositional Defiant Disorder."

The DSM-IV Desk Reference of the American Psychiatric Association describes ODD as "a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months." Some of the symptoms are losing one's temper, arguing with adults, defying adults or refusing to comply with adults' requests or rules, deliberately annoying people, blaming others for one's own mistakes or misbehavior, being touchy or easily annoyed by others, often being angry and resentful, and frequently being spiteful or vindictive.

Have you ever experienced these symptoms in yourself or others? Has it been a serious problem? According to the Desk Reference, the problem becomes serious if four or more of the above symptoms are evident, and if the behavior causes impairment in social, academic, or occupational functioning. Many recovering addicts can relate to this disorder. It has often been a way of life for them.

This subject came up at the recent Cape Cod Institute, sponsored by Albert Einstein College of Medicine. The presenter was Larry Silver, M.D., an award-winning child and adolescent psychiatrist in Washington, DC. He is highly respected in his field.

He says, "School is the life work of children and adolescents. If they are not successful in school, they often develop emotional, social, and family problems." But there may be other problems that underly the behavior. And one of them is ODD.

Oppositional Defiant Disorder may be the primary problem that leads to aggression, deceitfulness, and destructive behavior in the youngster, he notes. But what is the adult to do about it? "Start with some understanding that anything will work as long as we are consistent," says Silver. "Why should the kid give up the behavior if he or she is only punished part of the time?"

His ABCs of working with children involve three categories: Physical abuse (breaking things), Verbal abuse (words, tone, intention, noises), Noncompliance (not doing something after three reasonable requests).

Discussing "Time out," he says, "This is not a punishment. The behavior is not acceptable and you need to spend time thinking about the behavior." If the child delays the "Time out" more time will be added to it. The result of negative behavior is that the young people are in their room, and not functioning as part of the family. "With positive behavior, you're part of the family."

He advises, "Set up a system of rewards and consequences. Look at what sabotages you and label it 'not acceptable.' Don't step into the arena. Utilize a planned response system. Parents have to take control, and be consistent!" If the child indicates that he or she is going to stay out of the home and not come in, Silver recommends this response: "I will report you to the police as a missing child." What if a child trashes a room? Silver suggests, "Remove everything except the mattress and return the items one by one." Silver is emphatic about the need for the parent to gain control or the situation.  

One of his suggested approaches is the "earning points" model. Plan a day with various units of time worth three points if the youngster avoids unacceptable physical, verbal, or noncompliant behaviors. Say, "I'm delighted that you earned two points. I wish you could have earned three, but....." Use the end of the day or end of the week as a target for accumulating points, and reward high performance. But not "material rewards."

Rewards should be linked to "quality time." For example, more time with Mom and Dad, extra time to do things they enjoy doing, etc. Silver recommends that at the end of a week special interpersonal activity may be organized such as a family visit to McDonald's and visiting a park. "If they have earned 80 percent of the points they go with you. And count the points from Saturday morning to Friday night," he suggests.

"Maid Service" is another system he points out. "The child has to pay for the Maid Service."  All chores are listed, and a fixed rate for each chore is set. When the youngster fails to do a chore the amount is deducted from his or her allowance. "If money is no issue, use TV time, computer time, etc."

Silver emphasizes that love is an important part of this picture. "Love is unconditional," he says. "I will always love you, but I will not parent you if you abuse me." In most cases, if the parent stops doing things for the children, and acts as if they don't exist, this is a very painful consequence. 

He also recommends "reflective thinking" with children. "What makes you so upset?" "When you do that I get the feeling that......" And he says, "They have to take ownership of their own behavior. He recommends the behavioral approach first.

As for medication, this writer had the opportunity to ask Dr. Silver about Ritalin, and he said, "It's an appropriate treatment, but I prefer a combination of medication and psychotherapy, not one without the other."

Who's in charge? Not the kids. Dr. Silver asserts, "The goal is full control. And if the kid gains control, outside resources or hospitalization may be necessary."

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