Oppositional Defiant Disorder Treatment

Oppositional Defiant Disorder Treatment

Fig 1: Oppositional Defiant Disorder Treatment Relational Model. Download Media

In this post, I will cover the various oppositional defiant disorder treatment strategies and a real life ODD Case Study. For details on what is ODD and get an insight on some of the common ODD prevalence statistics, click here.

What Exactly is Oppositional Defiant Disorder?

Oppositional Defiant Disorder or ODD is one of the many diagnoses under the umbrella of autism spectrum disorders. This disorder manifests itself as a pattern of angry, irritable, defiant, nonaggressive yet vindictive behavior. Teens especially tend to refuse to comply with rules and restrictions.

They are nonaggressive, yet spend time planning vindictive reactions to things that annoy them. They deliberately annoy others and blame everything on someone else. For more details, please refer to the article on what is ODD.

Common Oppositional Defiant Disorder Symptoms

Here are some common symptoms of Oppositional Defiant Disorder:

  • Failing to Accept Responsibility
  • Verbal (or physical) hostility towards others
  • Persistent refusal to comply with instructions or rules
  • Easily annoyed, angered or agitated
  • Deliberately trying to push the limits (in a bad way)
  • Stubbornness to compromise with adults or peers
  • Being deliberately aggravating towards others
  • No respect for authority
  • Lack of empathy, treating others with disdain
  • Often co-exists with other disorders like ADHD or ADD
For a complete list of Oppositional Defiant Disorder Symptoms, please refer to the article on signs of ODD

Oppositional Defiant Disorder Treatment Strategies

For Parents

Treating oppositional defiant disorder involves several types of psychotherapy and training. Parents are often asked to be involved in the psychotherapy and training to assist the entire family in coping with this disorder. Treatment can last several months to years. Treatment for oppositional defiant disorder includes the following:

Parent-Child Interaction Therapy:

In this method the therapist coach parents while they are interacting with their child. Therapists generally are positioned behind a one-way mirror and communicate to the parents with an ear bug audio device… The therapist will guide the parent through strategies for more effective parenting techniques.

Family Therapy

Counseling for the entire family to improve communication and relationships

What is Oppositional Defiant Disorder Family Therapy

Fig 2: How ODD Family Therapy works

Problem Solving Training

This will help your child identify and change their way of thinking which is leading to their behavior issues. Both parent and child will work together to brainstorm ideas on how to solve an issue in a way that works for everyone. Refer to the guidelines below:

problem solving therapy for Oppositional Defiant Disorder

Fig 3: Problem-solving therapy for Oppositional Defiant Disorder. Download Media

Social Skills Therapy

Learning to interact positively with family and peers. Consult the OT (Occupational Therapist) on how you can achieve the following objectives:

  • Teach your child how to relieve anger and control temper
  • Keep an eye out for any passive-aggressive behavior traits, evaluate its effects on others and design eliminating strategies
  • Stress on problem-solving and communication skills. ODD often exists with ADHD which results in learning difficulties 
  • Encourage role-playing opportunities so that your child can become comfortable and confident while using newly acquired skills
  • Strive for positive reinforcements
  • Work with your child and rest of your family to address conflict, set clear expectations and set overall focus on improvement

Parent Training

There are mental health therapists trained to help parents develop their skills to handle problems that arise. You will learn how to avoid struggles, give time outs offer your child choices, establish schedules, routines and be consistent with your praise and consequences. The therapist would guide you on how to determine appropriate consequences that will not overwhelm your child. You will also learn how to keep calm, take time for yourself and most importantly, about positive reinforcement.

Positive Reinforcement will:

  • Allow the child to acquire new skills, become independent and increase self-esteem
  • Provide motivational boost to your child, thereby allowing the child to progress further
  • Keep the child focused on the task 

There are primarily 4 types of Reinforcement:

  • Social praise and recognition, such as high 5, clapping, hugs and kisses, cuddle and smile
  • Tangible rewards like toys, games
  • Favorite food such as chocolates, ice-cream, etc. for children who do not respond verbally
  • Token economy (works best for teenagers) such as allowance or money 

For Teachers

As teachers, use the following BFPF (Belong – Freedom – Power – Fun) formula. As parents, you also can apply the same cheat sheet while educating your child.

Belong
Loving, sharing & cooperating 
Freedom
Making choices
Power
Achieving, accomplishing, recognized & respected
Fun
Laughing & playing
Build cooperative relationships Avoid power struggles Be clear, consistent and fair Providing engaging and suitable activities
Build positive social skills Help ODD student understand and manage emotions Positive expectations Fun and energizing learning environment
Collaborate   Positive reinforcement  

Table 1: Oppositional Defiant Disorder Teaching Strategies

The Need for Praise

praising your childThe most important thing for you to remember is to be consistent with your actions and show unconditional love! Accept your child/student for who they are. This is a learning process for all involved.  Children, by their very nature, need and love attention, regardless of whether it is called or uncalled for.

As a parent, you must recognize and praise you child for positive behaviors. This should be an immediate praise such as “I really liked the way you helped your brother with the puzzle”. Be specific when you praise your child so they are aware of what you are praising them for. Be a good role model, and avoid power struggles. Set consistent schedules and stick to them! Children love routines and knowing what comes next. Use this to your advantage in setting limits and boundaries.

Make time for your child and you to interact. Even better, make time for the entire family to interact. Make sure that conversations revolve around consistency, praises, how to spend time together, routines and discipline. Nothing can pull the rug out from under you faster than inconsistency!

What is Oppositional Defiant Disorder solution? Make sure everyone in the household gets the same praises and consequences for their actions. Do not focus only on one child, for then, the child with ODD will start believing that they are in control of the situation. Initially, this involves a lot of hard work, however it will pay off with improved behavior and positivity towards your relationship with your child. Let me repeat one more time because its importance couldn’t be stressed enough: Routine, praise and consequences are key ingredients that you need to help your child with oppositional defiant disorder.

Oppositional Defiant Disorder Case Study

In this part of the post, I will talk about a real life ODD case study.

This is a real life ODD case study of Arthur (real name hidden for privacy concerns) whose case was handed to me from an international school in Caribbean Islands. This oppositional defiant disorder case study has been drafted from my personal experience as a behavior therapist. It is important to bear in mind that oppositional defiant disorder in children is different for each subject and hence the strategy adopted to treat ODD in children must be tailored to individual subjects.

Meet Arthur – A Child with ODD

Arthur - child with ODDI was first introduced to Arthur when he was twelve years old. The school contacted me as he was always complaining of being bullied when he did something wrong. He was a new student at the school and his records had no notations or indications that he had ever been diagnosed to be on the autism spectrum. After reviewing his previous school records, I researched his grades and grade level testing. He was performing at his grade level with good to average scores, yet there was no notation with regard to his conduct whether it is good or bad.

My First Day observing ODD traits in Arthur

I decided to attend his class as an observer. The teacher introduced me as a senior teacher looking for a class to place a teaching assistant. The class was pretty evenly split, girls and boys with a total of eighteen 12-13 year olds. Arthur’s desk was situated between a very cute blonde girl and a boy, a little smaller than he was.

The morning was uneventful until lunch break. The class was asked to complete their work and hand it in on their way out of the classroom for lunch. I had noticed Arthur appeared to be working diligently on his paper. On his way out the door he ripped his paper, crumpled it and told the teacher that the girl next to him had written on his paper so he could not do his work. The teacher began to uncrumple the paper. Arthur snatched it off and began to eat the paper!

The rest of the class was dismissed, yet Arthur remained steadfast in his spot in front of the teacher explaining over and over how the girl had ruined his work as he continued to chew the paper. Unfortunately, the teacher dismissed him for lunch as I sat there in utter amazement. His teacher indicated that this was quite common with Arthur. I picked up a piece of the torn paper that had fallen to the ground and on it was a quite detailed architectural drawing.

Our First Conversation

Later that day I spoke individually with several students asking questions about how they liked school etc. I also talked to Arthur. I asked him how he liked school – no answer and no eye contact. I tried again and he shied away muttering “what does it matter”. He did not know that I had seen his drawing so I asked him if he liked art and drawing.

Wow, his eyes lit up, he raised his head, made eye contact and began explaining to me in detail the principles of architecture and how he was going to be an architect. It was a pleasant conversation and I let him take the lead with the conversation.

Getting to Know Each Other

For a week, I returned to observe his class. For Arthur, every day something occurred that was someone else’s fault. And, every day he came to me and showed me drawings he had done and how he was using a Google program called Sketch up to design a house for me. I was a bit surprised that he said he was designing a house for me. However; I did not let him know that. I told him I was honored that he would want to design a house for me. He was all smiles. Yet, when his classmates were around, his head was down and he was drawing, constantly drawing. Every notebook and book had architecturally detailed inscriptions.

I met with the director again and we reviewed his records with a “fine tooth comb” and still found no mention of any behavior problems, no mention whatsoever of ant oppositional defiant disorder symptoms! This struck me very odd. One does not exhibit the type of behavior Arthur did without notice. I asked if the family would meet with me to discuss Arthur and they readily agreed. In fact, they made a big celebration out of a teacher coming to their home. My husband was also invited; this was to be a nice morning brunch with a discussion about Arthur and school.

The Brunch at Arthur’s

When we arrived the maid greeted us at the door. The house was immaculate. Arthur had a younger brother that was six years old. His mother was from Chile yet spoke impeccable English as well as German. I asked if dad was from Germany and the answer was no. He just liked the German culture and wanted his children to learn German customs and traditions. Both children and his wife were fluent in English, Spanish and German. When dad addressed me or my husband he spoke in English. When he talked to his wife or the maid he spoke Spanish. When he spoke to his sons he spoke German.

I was beginning to get an odd uncomfortable feeling. The therapist in me was now in full mode. The boys stood at the table until everyone was seated and dad gave a “command” in German and the boys sat. The boys were not allowed to speak, that was made very clear. Mom did not speak, other than to welcome us. I noticed the younger brother had a bruise on his leg and was acting quite normal for a 6 year old. Mom reached across the table to pass a dish and I also noticed a bruise on her upper arm that was supposed to be covered with her blouse.

The father did all the talking. He looked directly at Arthur and told him that I was there because he was tired of his misbehavior and defiance and that I would be hired to “fix the situation” or he would be sent to military school. Arthur did not respond, he kept eating as if nothing had been said. Dad said something in German, Arthur jumped up said yes dad and left the room. You could feel the fear in the air.

Alas, Yet another case of Domestic Violence

Oppositional Defiant Disorder and Domestic Violence

Fig 4: Oppositional Defiant Disorder and Domestic Violence

Instability, neglect, abuse, violence often accompanies ODD. Often children diagnosed with Oppositional Defiant Disorder have been or are in an abusive situation. The child becomes more aggressive and blames everyone else for whatever happens in their lives. This was what I believed to be causing Arthur’s problems at school. Of course, if you have an abusive situation where you feel any intervention would put the child in danger you must be very careful. It was very apparent to me there was going to be no help from the parents.

I agreed to work with Arthur and his father made a “deal” with Arthur. If Arthur behaved at school and home, did his work, stopped complaining then dad would hire someone with architectural experience to mentor Arthur to see if architectural design was in Arthur’s future? Arthur had little reaction to what his father said other than “yes dad”, again leaving the room.

The school year was almost over by the time I met Arthur and there was very little time for me to implement any therapy for Arthur, other than being a support system. Dad agreed to have me tutor Arthur during the summer. Arthur came to my home several days a week and the other days I went to his house. He was more at ease at my home. He was very polite, never made eye contact and often offered to help with things that were unrelated to schoolwork. Once he offered to do my dishes so I did not have to work so hard. This was coming from a teenage boy!

Giving Him What He Likes, or Not Quite

I incorporated architecture into his studies. His reading and grammar work was all related to architecture. He was not doing well with math and often expressed the attitude that he was going to be an architect, design and build me a house and he did not need math. I was prepared for this response. I asked him how he would figure out how many supplies were needed to build my house. His response was to delete the computer file and tear up the drawings he had done in his sketch book while running out the door. He threw himself into the swimming pool and purposely beat his head against the side of the pool until I jumped in and held him as tightly as I could.

Arthur calmed down and we sat on the side of the pool silently for quite some time. Arthur would not make eye contact nor would he say a word. I got up and told him I was going to go change my clothes and would meet him back at his home to continue our work. He said nothing other than I will still make you a house.

About a half hour later I returned to Arthur’s house to find him telling his mother that I threw him in the pool and made him hit his head and that his brother had deleted all his computer work. I was not surprised. What surprised me was his mother’s reaction. She sent him to the kitchen to have some ice cream, sent his younger brother to his room after reprimanding him for touching his brother’s computer and then she turned to me, eyes down and said “I am sorry Ms. Mary this is just the way it is, I know you didn’t push Arthur into the pool but this is how he acts when his brother upsets him” I had to take a deep breath as I looked into the kitchen to see Arthur laughing and pointing at me.

Blamig it on younger sibling is a common symptom of Oppositional Defiant Disorder in Children

Fig 5: Blaming it on younger sibling is a common symptom of Oppositional Defiant Disorder in Children

Mom disappeared into the younger brother’s bedroom and I could hear her admonishing the young boy. Arthur laughed even louder. I walked over to Arthur kissed him on the cheek and left. I called mom later and set up a time where we could talk. Dad is only home on the weekends as his job takes him out of town weekly. Mom wanted to wait and have me talk to his Dad “because it would cause trouble if she interfered with anything to do with Arthur”.

I am sure you can all see what was happening here. A fearful mom, beaten and abused children. Arthur with definite symptoms of oppositional defiant disorder and possibly other co-existing autism spectrum disorders all left undiagnosed. Abusive family life does not cause autism or oppositional deficit disorder, however it does enhance its effects.

It’s Time for Action!

I spoke to the principal at Arthur’s previous school. I told him what I thought was going on with Arthur. He stopped me in mid sentence and said “we know about the abuse”. Dad was a powerful man in town so it was never mentioned in public or school records, nor was the family approached about the signs and symptoms Arthur was showing off several autism spectrum disorders. “It would have made the family’s life worse if we had even suggested that Arthur was anything but perfect”.

When you have an abusive situation it becomes a matter of safety for all involved. In the United States, an anonymous phone call to Child Protective Services would have prompted an immediate investigation. However, this was not in the United States, it was in a small Caribbean Island community. The culture and the fact that I, along with this family, was a foreigner in another country also made this case difficult.

I could not walk away from this situation. I needed to find a way through therapy to help Arthur. The family was always respectful to me and encouraged me working with Arthur. For that, I am thankful as it allowed me the opportunity to work with him every day for over six months.

Arthur was old enough to understand that things were not right. However, he believed the abuse was his fault and he had no way to cope with his own feelings. His lack of eye contact, aggression, lying, hiding, not caring about anything but drawing his architectural sketches was what I had to work with (and without any support from the family). It amazes me till this day how they even entertained the idea of having someone work with their son, especially when they cared so little.

And the ODD Therapy Begins

architectural sketch 3
architectural sketch 1
architectural sketch 2

Fig 6: Some of these Architectural Sketched from Arthur were my crucial inlet points for ODD Therapy. Still, pretty neat stuff for a 12 year old!

The first week we did very little scholastic work. I let him talk, he was still not making eye contact, and if he would not talk I would ask him something related to architecture that he could explain to me. Hours were spent looking at his drawings that were hidden under his mattress – sketches of buildings on fire, monsters and children being eaten alive. The more I asked, the more he talked. It was a little over a week before he started to make eye contact. I brought him a book I had with Greek and Roman Architecture in it. That was the breakthrough moment.

He made eye contact and touched the book ever so carefully turning each page gently as he ran his hands over the drawings. The journey had begun, a door had been opened. Not only did I have to work on behavioral therapy I also had to worry about the parental response. Arthur began to look forward to my visits and waited daily at the door. He always had a new sketch to show me. We began opening up his circles of communication. He could tell me all about his drawing if I could teach him something new first.

The Bonding has Already Begun…

I lived within a few blocks of Arthurs home and he would now walk their dog past my house daily. He walked with his head down very quickly passed the house until I would yell out the door “Hello”. Every day I would see him in the morning and we would work on schoolwork and only then it would be time for him to draw or tell me about his thoughts or drawings.

I decided to add in game-playing to see how he reacts to winning and losing. It was a simple game of ‘Sorry’ and he won the first two which excited him to want to play a third round. When he lost the third game, destroyed the board, ripped the cards and threw the pieces at his younger brother while running to his mom pointing at the mess and telling her that his brother had done it. Mom knew the truth however her reaction was much the same as it was months ago. Younger brother punished, Arthur unpunished and Arthur smiling at what he had “accomplished”.

Arthur had come out of his shell, let me in to work with him, however because of his undiagnosed condition and lack of behavioral therapy at a young age, the rage would come through. Over this time span his outbursts were less and less, in fact, when this incident occurred he had been doing very well and expressing his feelings in his notebook and discussing them with me.

Using a Journal as a Private Gateway

Using a Private Journal - Great Tool to treat a Child with Oppositional Defiant Disorder

Fig 7: Using a Private Journal – Great Tool to treat a Child with Oppositional Defiant Disorder

The use of a private notebook or journal, allowing a child to draw or write how they honestly feel without the fear of being judged is a great tool. It opens an avenue for the child to express what is bothering him/her and provides an inlet for the therapist to take on a role of positive reinforcement, never criticize, always agree with the thoughts behind the sketches and enter into an ice-breaking conversation like, “I see, now let’s think what would happen if we did this”. The journals, notes, and drawings are their true feelings that are trapped without a way out. You, as a parent must find a way to incorporate positive into the negative.

Arthur came to my house later that day, without his dog, and apologized for what he had done; he made eye contact and was truly apologetic, more so with a slight hug. “I don’t know what to do because everything seems to be my fault”. I called his mom, told her where Arthur was and that he was going to have a snack with my husband and I before getting back home.

And the Breakthrough!

I had two pamphlets on my desk on spousal and child abuse. Arthur saw them and asked if he could look through them. He studied them carefully, silently reading, looking at the pictures and scanning through my desk top to see what else was there. I had (on purpose) a page open in a therapy book about ODD. He held the brochures tightly in his left hand as he read the article in the book. He turned to me and said “All of this is me, isn’t it Ms Mary?” He had put two and two together to realize that he had an undiagnosed condition AND a horribly abusive life. He cried, the first tears I saw! He hugged me tight, the first real genuine expression of his feelings. You could feel his relief leaving his body and soul.

“I am not a bad, terrible, crazy person as my dad says”! It was an astonishing moment and a great breakthrough for Arthur. Yet he knew as well as I did that he had to return to that environment. I decided he should come to my house for his tutoring and therapy where he could express himself freely. Mom agreed. Dad was hesitant however he finally agreed; that man needs a therapy, I tell you!

Meeting the Grannies

Grandma and Grandpa came to visit late in the summer, very nice fellows. These were Arthur’s maternal grandparents and they live in Chile. I continued to work with Arthur, had several interactions with the grandparents and things were progressing. I found out that his grandfather actually owned a contracting business that built homes and schools. This explained where Arthur has inherited this obsession with architecture and I was delighted to see how close he was with his grandparents.

One evening my doorbell rang and it was Arthur’s grandparents. Grandpa did all the talking. Grandma was in tears as he spoke. Grandpa said he knew that his son in law was abusive and that he, Arthur’s dad, was diagnosed with autism when he was young. Grandpa was very open and expressed his sorrow at how his daughter stays with him and how the children were treated. He asked if I knew something that would help. You see, Arthur’s dad had approached grandpa and demanded he provide the income for Arthur to study architecture or he would send him alone to attend a military school which he also wanted the grandpa to pay for.

I was very moved with the grandparents concern and the true regret that they were feeling for not having spoken up sooner or been more forceful in removing their daughter and grandchildren from the situation. It is unfortunate that things like this happen all too often in life.

It indeed was a time for law to intervene. Thankfully, Arthur’s grandparents were affluent and I was able to persuade them to demand custody of the 12-year-old boy. I testified, in the capacity of a qualified medical practitioner, that Arthurs was a child with special needs and the presence of his (abusive) family is detrimental to his formative development. His father didn’t seem to complain much, nice riddance he must have thought!

Undiagnosed, abuse, no one caring or daring to get involved, For Arthur this was the start of a new life. The grandparents were given custody, took Arthur back to Chile with them.

Fast-forward 4 years..

Arthur is now 16 years old and has already graduated high school. He is on a medication for his disorder and is working with his grandfather in their construction business. He designed a new house for his grandparents and is overseeing the project management along with his grandfather.

Arthur and I Skype and email often which allows me to monitor his progress and he is always so excited to tell me how great he feels. Arthur has not seen his parents since he went to live with his grandparents, nor have I been able to have any contact with the family (for obvious reasons). His grandparents and I are very proud of him. He finished high school early with good grades and is doing something that he has a passion for. He continues with therapy to handle anger management issues, but all in all he is functioning and performing so well that I am encouraged that someday it will be Grandpa and Grandson’s business!

2016-10-19T10:15:39+00:00 December 26th, 2014|Categories: DIAGNOSIS & TREATMENT|Tags: , |1 Comment

One Comment

  1. teddybowties January 16, 2016 at 9:27 pm - Reply

    oh my. so beautiful. we will never meet, Ms. Mary, but, as a stranger who thinks my family may have this and other issues going on in terms of ODD and ADD and Autism and such, thank you. thank you for wakening little Arthur to the joy of self knowledge. there is no greater gift you can give a person, than to lead them to themselves. thank you. thank you.

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