“You can’t make me and I don’t want to”.
Oppositional Defiant Disorder. A Parenting Nightmare
Child and adolescent therapists are often consulted by parents who are at the end of a long and bumpy road with teenagers. Families describe behaviours that have become increasingly defiant or confrontational.
Teenage mental health specialists will often use the term ‘oppositional’ to describe the direct challenges that happen at home, at school or in situations of perceived authority.
In the intake assessment, parents may describe how the troublesome behaviours started earlier in childhood. Usually, parents have been able to manage the moderately oppositional behaviours at home, with the help of school or extended family.
When Parents, Educators or Families call in mental health professionals, it is usually because the behaviour has become thoroughly disruptive to family life or there have been serious fractures in education or run-ins with the law.
The difference between ‘Normal’ Teen Challenges and Oppositional Behaviour
The Teenage years are a period of rapid change.
It is the time when young people go through changes on the inside and the outside. Trying new behaviours, finding the right ‘fit’ and experimenting with decision making is on the to-do list for every Teen.
Sometimes, this involves pushing back and challenging the status quo that has been established in earlier childhood.
While most young people will have a period of disagreeing with Mum and Dad; maybe slamming the occasional door or coming home late once in a while. The hallmark behaviours of the teen years may take some navigating for many families with peace being restored in a reasonable timescale.
The difference in the developmental pathways lies in the frequency, persistence and prevalence across differing situations.
It is important that parents take into account not only the age, gender and culture but also factor in any trauma or developmental delays.
“My son always went that bit further. More argumentative, more disruptive, more worrying for Me and his Dad”.
What is Oppositional Defiant Disorder?
Oppositional Defiant Disorder or O.D.D. can be found under the Disruptive, Impulse-control and Conduct Disorders criteria in DSM-5 (A.P.A.).
O.D.D. involves issues relating to the self-control of emotions and behaviours, including aggression, destruction of property, argumentative and conflict producing behaviours.
Whilst O.D.D. is more often seen in boys; it is also seen in girls with slight variations in the presentation in some cases.
Angry/Irritable Mood
- Often loses his/her temper
- Is often touchy and easily annoyed
- Is often angry and resentful
Argumentative/Defiant Behaviour
- Often argues with authority figures or adults
- Often actively defies or refuses to cooperate with requests or acknowledge rules
- Often deliberately annoys others
- Often blames others for his/her mistakes or behaviour
Vindictiveness
- Has been spiteful or vindictive at least twice in the past 6 months.
The behaviours are usually noted to cause distress to others in the immediate vicinity; school, home, family peer group.
This can have an impact of the functioning at home, school or in friendship circles.
- Mild – Symptoms generally appear in one setting (home or school)
- Moderate – Symptoms are present in at least two settings.
- Severe – Symptoms are present in three or more setting.
Young people and Teenagers who demonstrate O.D.D. type behaviours most often do so at home in the first instance. Children and Teenagers will often not view themselves as angry or disruptive. They may go to great lengths to explain that the behaviours are a response to unfair, unjust circumstances or unreasonable demands.
Oppositional Defiant Disorder Pre Teens and Younger Children
All children demonstrate some level of antagonist or annoying behaviour, especially at home.
In children younger than five years, to meet the criteria, the behaviour should occur on most days for six months or longer. Younger children who meet the criteria for early diagnosis may move into a period of more settled behaviour in the pre-teen years. Developmentally, at around eight or nine, most children try out age-appropriate independent thinking. They become slightly better at describing their emotions and intense feelings. This may be a period where some children seem to ‘grow out of’ the more destructive behaviours.
Those who continue to meet the criteria for diagnosis should be regularly reviewed by their Paediatrician and a Chid and Adolescent Psychiatrist, where appropriate.
O.D.D. is not a “boy thing”. Oppositional Defiant Disorder can affect girls too
The symptoms of O.D.D. may look slightly different in girls when compared to those seen in boys. Boys tend to demonstrate more signs of physical aggression, are more prone to threaten violent acts and have explosions of anger which may lead to the destruction of property. Similar related topics to behavioural issues in girls can be found via our ‘ADHD in Teenage Girls and Young Women’ blog.
Girls may show some similar demonstrations of aggressive and angry behaviour. They are also seen to show more indirect means of defiant behaviour; lying, manipulating and refusing to cooperate. They may escalate minor disputes into more serious displays of aggression, using threats of self-harm or suicide when challenged.
Children who identify as Transgender may also have difficulties expressing anger and frustration. Parents need to take care of mental health issues for transgender children by consulting a supportive mental health professional.
Attention Deficit Hyperactivity Disorder (A.D.H.D.)
Oppositional Defiant disorder is much more common in children, teens and young adults previously diagnosed with A.D.H.D. Around 4 out of 10 children with symptoms of A.D.H.D. will also meet the criteria for O.D.D. There is no universal agreement on why the conditions are so often found in tandem.
Depression and Oppositional Defiant Disorder
Parents and professionals may invest much of the therapeutic input into helping the family navigate and challenge the oppositionality. Occasionally, Teenage Depression may be overlooked as the system works together in managing and successfully treating the O.D.D.
Depression can co-occur in young people diagnosed with O.D.D. Depression in Young People and Teenagers can manifest is slightly different ways to those that we may be used to seeing as presenting symptoms in adults. Aggression, confrontation, irritability, pervasive low mood, sleeping to much or too little, use of drugs or alcohol, self-harm, changes in eating patterns and thoughts or discussions of suicide; require investigation by a mental health professional.
Children and teenagers with depression may report physical symptoms, tummy aches, headaches, feeling sick and may ask to be absent from school or other activities. Oppositional behaviours such as screaming, yelling, angry outbursts can also be evident in depression in teens.
It is important to seek advice from a child and adolescent psychiatrist or mental health specialist.
Psychotherapy and Counselling are beneficial for young adults and teenagers experiencing symptoms of depression or low mood. Outpatient services, individual therapy and family therapy are a great place to start.
Mental Health professionals will often refer the young person to residential treatment centres with specialist programs for teenagers should further intervention be necessary.
Intimidating Behaviours. Teens who threaten in the home
There are times when intimidating behaviours at home are frightening for parents and siblings. This type of behaviour is different to usual shouting, yelling and tantrum-like behaviours seen occasionally in many children and teenagers.
Teenagers who threaten violence, intimate that they will cause harm or injure others can cause incredible levels of fear in the home. Blocking doors, taking car keys, smashing items in the home and destroying property is something that needs to be addressed. It will not usually subside without intervention.
Some Teenagers and Young Adults begin to violate the rights of others, show aggression towards family members or animals, steal from home or destroy property. These young people may show a lack of empathy. It may become apparent that they show little care of understanding for the physical or emotional distress that they cause to those around them. They may appear cold, unfeeling or callous. Parents may be fearful of their actions or have been hurt or abused by the teenager in recent times.
Parents may notice an increased level of manipulation from their teenager, as they impose devious ways to get what they ‘want’. The teenager will go to almost any lengths to control others.
Parents describe feeling afraid in their own home. Often they hide, lock away valuables or install additional home security measures. There may have been death threats to the family, violent outbursts and increasing levels of discord in the home.
Children, Teenagers and Young Adults who exhibit these behaviours may have reached the threshold for a formal diagnosis of Conduct Disorder.
What is Conduct Disorder?
Research suggests that there is a developmental link between O.D.D. and Conduct Disorder. This really means that those young people diagnosed with Conduct Disorder would have previously met the criteria for Oppositional Defiant Disorder, this is most evident in young people who meet the threshold for diagnosis of O.D.D. prior to adolescence.
Conduct Disorder is a relative, and persistent pattern of behaviour that impacts the rights of others, normal societal ‘rules’ and negatively impacts those close to the young person or Teen.
DSM-5 (American Psychiatric Association) lists the following criteria for diagnosis:
Aggression to People and Animals
- Often bullies threaten or intimidate others
- Often initiates physical fights
- Has used a weapon that can cause serious bodily harm to others (e.g. a bat, brick, broken bottle, knife, gun)
- Has been physically cruel to people
- Has been physically cruel to animals
- Has stolen while confronting a victim
- Has forced someone into sexual activity
Destruction of Property
- Has deliberately engaged in fire setting intending to cause serious damage.
- Has deliberately destroyed other’s property (with the exception of fire starting)
Deceitfulness or theft
- Has broken into someone else’s house, car, building or other
- Often lies to obtain goods or favours or to avoid obligations (‘cons’ others)
- Has stolen items of nontrivial value without confronting a victim (Shoplifting, forgery)
Serious Violations of Rules
- Often ignores curfew times or parental prohibitions, starting prior to age 13
- Has run away from home at least twice from the parental home or at least once for a lengthy period
- Has been truant from school before the age of 13
Conduct disorder may be evident before the age of 10 or maybe seen to begin in adolescence.
Conduct disorder can have serious implications for the young person concerned and the family. It is imperative that mental health services are consulted, and a treatment plan agreed with the child and family.
Concerns for the future?
Parents and families are sometimes concerned about the future. Education that has been disrupted can often pave the way for a period of increased uncertainty. Hopes and dreams for the future can feel unattainable.
Teenagers and Young Adults reviewed in treatment services have varying levels of oppositionality. Families have varying levels of resilience, resolve and motivation to change. The outcomes are dependant on a combination of all.
Children and Young people who have shown defiant or difficult behaviours in the home, whilst managing relatively stable relationships with others and who have managed to get by with only minor scrapes at school, tend to move forwards and stabilise in their late teens to mid-’20s. Showing reasonable decision-making skills, ability to hold friendships, inclusion in social activities and minimal violent conduct sets these young adults apart from those with more pronounced behavioural difficulties.
Children who exhibit a greater involvement in violent conduct, inside or outside the home may require further intervention. Violence at home does not necessarily need to be physical to meet this criteria. Extreme verbal assaults, name-calling and abuse should prompt the parents to seek further help. Young people who continually break the family rules, steal, lie and manipulate or threaten violence in the home, should prompt a red flag warning for parents and carers.
When children and teenagers learn that this behaviour has little consequence, when parental boundaries are porous or when they can bully type family enough to routinely ‘get their own way’, the trouble starts to set in. Parents who give house room to destructive, threatening, abusive behaviours in the hope that a quiet life or change is around the corner are setting the scene for prolonged distress.
Children who learn to control their environment in this way can go on to exhibit the same behaviours in the wider community. Teenagers who continue argumentative and oppositional attitudes outside the home can find themselves alienated and on the fringes of life. They frequently see little reason to change their behaviours, adopting an “I don’t care’, “I don’t know’ or “You can’t make me” position. The ramifications outside the home are of course less predictable than those in the family, with consequences that are governed by legal process.
Children and teenagers who demonstrate violence or destruction when angry, frustrated or not able to control any given situation, who also demonstrate a lack of empathy and regard for others may have a more difficult path into adult life.
Antisocial Personality Disorder
Antisocial Personality Disorder is described as, ‘a pattern of disregard for, and violation of, the rights of others’. (DSM-5., American Psychiatric Association). This includes many of the elements discussed in O.D.D. and Conduct Disorder; however, it is seen to continue in adulthood. Diagnosis is not made until after the young persons 18th birthday.
There is a correlation between Antisocial Personality Disorder and Substance Disorder, with figures reporting up to 70% prevalence of both disorders in forensic and rehabilitation settings.
When to get advice?
We advise parents to take advice from a Child and Adolescent Psychiatrist or Mental Health Professional at the earliest opportunity. We know that children and young people who are engaged with long term treatment services (residential treatment for young people, outpatient services or acute services) appear to have a greater chance of long term recovery.
Parents often describe feeling overwhelmed and ashamed. They can feel guilt and responsibility for the actions of the young people affected. Many parents blame themselves, school moves, long working hours, divorce, or other major life events. It is important to find a good family therapist. The family with the support of the therapist and psychiatrist will be able to find structure and strategies to work through the difficulties and restore a sense of harmony within the family system.
When childhood trauma is evident, parents should look to work with a treatment team that is trauma-focused. The most effective treatment will allow the young person the opportunity to work through trauma and behavioural aspects together. Sometimes children and teenagers who are hurting inside, hurt others. Helping them to be seen and heard can help to reduce the external feelings of anger, shame and resentment.
The number one parenting tip is to reach out for help. Sharing your concerns will help. Finding a treatment team to support the changes that need to be made is essential.
All Young People need a chance to make better decisions.
Fiona Yassin is the International Clinical Director at The Wave based in Kuala Lumpur. Fiona has assisted many families from all over the world to find solutions to behavioural disorders in children and young people. Fiona is a Child and Family Trauma Professional, Fellow of A.P.P.C.H., a member of F.D.A.P., and I.E.A.D.P. Recently completed Post Graduate training in Psychiatric Disorders in the Female Population with Massachusetts General Hospital. She is an Accredited Clinical Supervisor (U.N.C.G.). Fiona is currently undertaking E.M.D.R. Training (E.M.D.R.I.A.) in the U.S.A. and additional Post-Graduate Masters level Trauma Training with Glasgow University.
