Oppositional Defiant Disorder, or ODD, can be traumatic to deal with.
A child's oppositional or defiant behaviour needs to be consistent and obvious for about 6 months, before it's classified as ODD. This can seem like a long time before parents make decisions to do something about it.
Dr Shan Ong is a developmental paediatrician with deep experience in this field.
I spoke to him on the Learning Capacity podcast, and asked about ODD. What does it mean for parents to take the first steps in handling the situation? And what can parents expect? Dr Ong explained that for parents it's a mixture of emotions from relief to denial. They have to come to terms with the long road ahead.
We also talked about the role of the child's school. How the school fits in with strategies at home. And the relationship with a medical professional.
I started by asking Dr Ong to clarify what defiant behaviours might look like.
Listen to the discussion:
- Oppositional Defiant Disorder (ODD)
- Attention Deficit Hyperactivity Disorder (ADHD)
- Autism Spectrum Disorder
People & organisations mentioned
- ADHD parent support groups
Previous podcast episodes on SoundCloud
If you would like to read the complete podcast transcript, here it is:
Episode 50 of The Learning Capacity Podcast
Dealing with Oppositional Defiant Disorder. Dr Shan Ong Discusses the First Steps for Parents
Colin Klupiec: Dr Ong, thanks for joining us.
Dr. Ong: You're Welcome.
Colin: We're discussing ODD today, or Oppositional Defiant Disorder, and this can be a very traumatic thing to deal with and for parents to come to terms with, or even indeed the children themselves to come to terms with. Literature seems to state that behaviors of defiance need to be consistent for about six months and need to be fairly obvious for those six months. Can you clarify for us what those behaviors might look like?
Dr. Ong: Those behaviors mainly involve being oppositional i.e. going against authority figures, so in the family situation would be a child going against the wishes of their parents and so being argumentative. They would often oppose many things that their parents would want them to do, and it could be as simple as normal activities of daily living like brushing your teeth, having a shower, getting up and getting dressed for school.
It could involve doing homework. But it should also occur in other situations like at school, or in other social environments with other people as well, and not just be confined to one particular situation. When the oppositional behavior is pervasive across different environments, then we start thinking about calling it a disorder rather than saying that the child has got just traits or features of oppositional behavior.
Colin: So throughout the observation period, if I can call it that, I mean there would have to be a point where you would start suspecting that something is up, and so you suddenly find yourself in a period where you're observing things more than you have been in the past.
I would assume that there would be some common emotions that you would see amongst parents when they realise that something is up. When they realise that they need to address some kind of a problem. Is that assumption correct? I mean do people start to experience a particular anxiety or are parents worried about this sort of thing? How have you found that they react?
ODD, ADHD & Autism
Dr. Ong: I think a lot of parents, by the time they come and see me and the child has oppositional behavior, they are often worried and frustrated. There are those parents who are feeling tired and worn out because of the constant fighting and arguments with their child.
But often, Oppositional Defiant Disorder more oftenly occurs in conjunction with another behavior disorder such as Attention Deficit Hyperactivity Disorder or ADHD, or Autism Spectrum Disorder. It is quite uncommon for ODD to occur on its own. So often, parents are having to manage those other issues associated with ADHD or Autism, as well. So yes, the combination of all those behavior difficulties, most parents are either worried or they're actually getting worn out.
Colin: Do you see much denial happening with parents?
Dr. Ong: Yes, there are some parents who are in denial. I find that it's usually the fathers who are more commonly in denial than the mothers. I think that's because the mothers are the ones who tend to spend more time with their children. They're the ones who are usually in contact with the schools who might be having trouble coping with their child's behavior. And I think a lot of the fathers, being so busy with their work and careers, they don't see so much of their children's behavior issues.
Colin: So assuming that the parents have arrived at a point where they know that they need to do something and they're willing to take some action, how do you initiate conversation with them? So where I'm coming from is, what are the pain-points that you need to be aware of when you first talk to parents in order to make them feel comfortable
Dr. Ong: By the time a parent would come to see a developmental pediatrician like me, they would have gone through a process of seriously considering whether there is a problem with their child. They would have to discuss these questions amongst themselves before coming to see me.
So when they see me, I find it quite easy to get them to speak and explain what their concerns are about the child and describe the child's behavior. And in so doing, I find that a lot of parents start to feel a little bit more relieved because they are speaking to someone who actually has an understanding of what they're going through.
You know there are those parents who doubt themselves and think that perhaps their child's behavior issues are due to perhaps not very good parenting skills. But when they're able to actually sit down, get these things off their chests and discuss it with me, they often start to feel more at ease.
Colin: I can imagine, as you were saying before, the parents might be very worn down or exhausted by the constant defiant behavior at home and they're probably getting a lot of phone calls from the school I would imagine, as well. I can see a little bit more now how a parent would actually come to you and just be relieved.
In fact, in some of the conversations I've had with other people about some of the other conditions that you were referring to, and I'm thinking about even things like Dyslexic problems or learning disability problems in general, there is an enormous amount of relief.
So I imagine that's a fairly long road to progress or possibly, even an endless road. I mean this is not the sort of thing that you can fix overnight. How do you communicate the time factor involved?
Dr. Ong: A lot of parents are able to understand that quite easily because they would have been struggling with their child for quite some time already. They seem to have that understanding that if there's going to be change and improvement, it's going to take some time. I haven't had anyone actually ask me for a short-term remedy.
I do often explain to them that it involves, the management of this involves changing the way they may be speaking to their children, changing the strategies that they use for their children. It may involve consultations with other professionals like child psychologists who may counsel their child or more commonly provide specific behavior management strategies to the parents.
I'd like to get parents to inform and educate themselves about this condition so I would usually recommend one or two books for them to read. As they gather this information, I think they start to realise that there is a process involved and therefore, time involved in getting their children to improve.
The question of medication
Colin: So practically speaking, you are alluding to a few things that happen there. I'm just wondering what are the sort of strategies that you might get the parents to work with their children on? And you know, other questions might arise as well, like does medication ever come into the equation?
Dr. Ong: Medication sometimes comes into the equation. I would prescribe medication or recommend medication if the child also has a diagnosis of ADHD. The thing about ODD is that most children with ODD actually have underlying ADHD to begin with.
What the literature tells us is that there are a lot of children with ADHD and that sort of becomes more manifest when they're quite young, usually from the age of two. And by the time they are about five or six, there's quite a large percentage of them, you know, about 50% to 60%, start to develop oppositional behaviors.
And then some of those children develop more extreme oppositional behavior and end up getting a diagnosis of Oppositional Defiant Disorder.
So we tend to understand ODD in terms of a condition that has developed out of a pre-existing ADHD. So by treating the ADHD part of that with medication, we do find that a lot of children make huge or significant improvements with the ADHD behaviors.
The ADHD behaviors I'm talking about are the lack of attention and concentration and restless impulsive behavior. But because those behaviors improve, there is a flow-on effect on the oppositional and defiant behaviors and they start to improve as well.
There is no specific medication that directly treats ODD, but we do find that if we treat the underlying ADHD with medication, then the ODD starts to improve.
Self regulation once ADHD settles down
Colin: So in simple terms, am I hearing that it's a case of children being able to self-regulate better once the ADHD settles down because of the medication, that they're able to process situations better and deal with personal interactions in a more effective way?
Dr. Ong: Yes, that's right. Those words that you said, "self-regulate," that's all important in a child with ADHD and ODD because these children have difficulties self-regulating. They have trouble controlling themselves. So in the ADHD scenario, yes, we call it an attention deficit where they have trouble with their attention and concentration skills.
But that involves having trouble with self-control, having trouble controlling themselves to stay focused on tasks that require sustained mental effort and that don't give them pleasure. Because we know that all children with ADHD, even the severe ones, will be able to concentrate on a computer game or an iPad game for hours, and not show any signs of attention deficit in that particular circumstance.
And that's because the pleasure, the joy they get from those games drives them to continue playing those games. They don't have to control themselves to stay focused on those things.
But then give them something that doesn't give them pleasure, like school work for example, or a chore at home, that's when they would then have to control themselves to stay focused on those tasks. But because of the disorder, they cannot do that. And that lack of self-control also involves controlling their emotions.
And so these kids have a tenancy to get over-excited more easily and have trouble settling themselves back down or they could get anxious more easily or angry more easily, and have trouble coming back down to a more neutral level with their emotions. What we see with a lot of kids with ODD is that a lot of them have trouble with anger management.
They get angry when they're asked to do something they don't feel like doing. And because of that lack of self-control, you see more anger, either more extreme anger or getting angry a lot more easily. So with medication, you help with that self-control. You see the anger diminishing or settling down. It certainly does have an impact on the ODD behaviors.
Colin: That's a fascinating relationship you make there with the ability to attend to a video game or an iPad game where they show no signs at all of any ADHD, but then when you ask them to do a simple thing, suddenly the oppositional behavior kicks in.
Is that because when they get asked to do a menial task or a chore or something like that, there is nothing triggering in the reward center of their brain. There's nothing interesting about that so the self-regulation or the lack of self-regulation kicks in and says, "I don't know how to process that. I'm just going to oppose it."
Dr.Ong: Yeah, that's right.
Get parents, medical practicioner & school working together
Colin: Some literature that I've come across in the past suggests that a three-way connection between the home, and a medical practitioner such as yourself, and the school is a good way forward. In your opinion, how involved should the school be in the overall treatment of the situation?
Dr. Ong: Well, I think the school should be heavily involved because the school is looking after the child for a good portion of the day, seven, eight hours everyday. The school has to cope with the same sort of behavior issues at school. A lot of children with ODD can be less oppositional at school.
That's perhaps because the environment is more structured.Because of the social component, they don't want to misbehave too much in front of their peers, or because they have a bit more respect or fear of the teachers there. But I find that if the school can actually work together with the parents in terms of managing the child's behavior, you do end up getting a more successful outcome.
Colin: We often think primarily of helping the child, and earlier in the conversation, you were saying you were talking about encouraging the parents to educate themselves on the condition of ODD. But in general, for support for parents, what kinds of support are available for them other than just reading up about the condition?
Dr. Ong: There are parent support groups. I don't know if there is a specific parent support group for ODD but there are definitely parent support groups for ADHD and for other conditions like Autism Spectrum Disorders, as well. As I said, the majority of kids with ODD also have ADHD so a lot of parents should be able to access parent support groups with ADHD. The easiest way to find them is just to type "ADHD parent support groups" into Google.
Colin: So that simple in that respect?
Dr. Ong: Yes.
Colin: Just look one up that happens to be in your area?
Dr. Ong: Yes, and every city in Australia would have an ADHD support group.
Colin: Okay, so assuming that we're well on the path of handling a particular case, this is a fairly large and open-ended question, but what does success look like
Dr. Ong: That is a very good question. For a lot of these families, success can actually be small steps. Success could be a child successfully remaining at school or a child successfully not being suspended for a term or for a whole year even.
Success could be a child not declining in their school grades academically. Success could be parents not separating and divorcing because they can't cope with the child's behavior.
Colin: So it's a multi-factorial situation in where there could be one or many of those factors kicking into to give some sort of an indication of success. Have you ever seen situations where there is just whole-sale success, like it's really worked right across the board, or is that the impossible dream?
Dr. Ong: No, that's not impossible. I've seen a lot of success where families haven't broken down, that the child's behavior turned around completely, that the child's attitude towards school turned around completely and the child's grades actually started to improve.
This change has been brought about by being treated with medication, as well as seeking psychological intervention like counseling for the child and the parents.
Colin: Does the medication come to an end or does it tail off, or do some people stay on that path for a very, very long time?
Dr. Ong: With medication, it's usually a long-term treatment plan because the medication does not bring about a cure. The medication does help with the behaviors and the difficulties. But if a child were to stop medication, then the effects, the benefits will disappear almost immediately.
So a lot of these children would need to continue on medication for a few years at least. Some of them may continue it through their school years but a lot of children are able to stop medication by the time they finish high school.
Colin: So on the whole, just coming back to the idea of success, properly managed, the future can look very bright.
Dr. Ong: Yes, definitely.
Colin: Assuming that everything aligns correctly and that everyone is on board and things work well.
Fathers can make a huge difference
Dr. Ong: I think what is key is everyone being on board. The difficulties that I actually come across is when both parents are not on board. I think it is terribly important that both mum and dad are on board and are on the same page with the child, with what's happening with the child.
Often, the schools are on board because the schools are struggling with these children and so they're the ones who often initiate the process to come in to see a doctor like myself or for the parents to seek help. But what I find when a situation does not succeed, it's often because both parents are not on the same page.
I find that fathers play a very big role in these children's lives.They don't quite realise how powerful their role can be. I mean the traditional model of parenting is that mums are the ones who nurture and bring up the kids, and therefore do the bulk of the parenting, and dads are the ones who go out into the workforce to support the family financially.
But I find the longer I do this kind of work, I find more and more that fathers, if they were to get more involved in their children's lives, they make a huge difference. By just being there, just by being present, they can start to make a difference.
Colin: Dr. Ong, that's very insightful. Thanks so much for your time.
Dr. Ong: You're welcome.