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Deconstructing Oppositional Defiant Disorder

April 27th, 2017 | 36 Comments | Blog

By the time Stuart hit second grade, his teachers had pegged him as a “problem child.” They knew he came from a loving home and could discern right from wrong, but still, he frequently started fights and caused classroom outbursts. By tenth grade, he had been in and out of various therapies and special schools. His primary diagnosis: oppositional defiant disorder, or ODD.

Was the diagnosis accurate, or useful?

Many parents have contacted me since my post questioning whether ODD is a valid diagnosis. I described it from a neuroscience perspective as an indicator of a child’s threat-detection system gone awry. This new perspective views persistent oppositional defiance as a child’s pattern of behaving defensively, even when the child isn’t actually facing a threat. The cause, according to the preeminent neuroscientist Dr. Stephen Porges: challenges in a child’s neuroception, the subconscious capacity to detect safety and threat.

I’m not alone in questioning diagnoses such as ODD. The National Institutes of Health (NIMH) has made it clear that diagnostic categories are not useful treatments guides, as they were long perceived. In 2013 the NIMH stopped funding research based on the diagnostic categories of the DSM, the “bible” of mental health. Why? Because research showed that it’s more important to identify underlying causes than merely to check off symptoms on a list.

So, we need to take a closer look at and deconstruct ODD.

We also need to abandon old models treating a child with an ODD diagnosis as needing to work on simply becoming more compliant—essentially, blaming the child. Too often, we assume that what a child or teen needs is better behavioral management, more consistent parenting, or better medication. But current neuroscience shows otherwise: the behaviors we label in ODD are actually ways of responding to stress. They indicate a pattern of underlying emotional dysregulation that regularly sends the child into a fight/flight response.

The concept of neuroception has the potential to enlighten clinical thinking when developing treatment plans for children and teens. It turns traditional thinking on its head: ODD is not a “thing” to be cured, but an indicator that the child is experiencing severe and often unpredictable stress responses. To help children exhibiting these responses, we need to offer supports to help children (and caregivers) feel safe, and not blamed.

If you are a parent, you may have been given messages simplifying ODD such as:

—Inconsistent parenting or discipline is causing your child’s behaviors.

—The “disorder” is causing the behaviors.

—You should clamp down and create more rules and structure so your child understands that these behaviors will not get positive reinforcement.

We need to shift that thinking with these counterpoints:

Many children from a wide variety of backgrounds are diagnosed with ODD. Of course, neglectful or abusive relationships cause mental health insults, leading to a wary threat-detection system and, in turn, oppositional or defiant behaviors as a response to trauma. But many children from stable families are also diagnosed with ODD. When we look closely at these children, we often see in the child’s early history an emotional vulnerability and tendency towards fight-or-flight reactions to a wide range of triggers, including seemingly innocuous ones.

Don’t blame the disorder. As Dr. Porges explains, fight or flight behaviors are the result of the subconscious threat detection system (neuroception) falsely sensing danger. This conceptualization involves underlying brain feedback systems, rather than thinking of ODD as a specific disorder with a specific cause.

Discipline isn’t always the answer. The way to help children feel safe is not more rules and punishments—which make the child feel blamed—but rather personal attunement to helping the child manage these intense stress responses. We need to become investigators as to the range of individual differences that contribute to children’s emotional vulnerability, and help them construct new meanings from the sensations they experience leading to the challenging behaviors. Also, our most vulnerable children—including foster children, and those in the child-welfare system—who have experienced early trauma may be re-traumatized by behavioral approaches that make them feel alone and relationally unsafe.

Seek the right professional. Find a therapist who understands that oppositional behavior is an indicator of chronic stress responses. Be wary of those who urge “behavior management” in isolation from supportive and loving relationships. Avoid treatments that focus solely on observable behaviors separate from what is causing the emotions. (School teams may not be aware of or fully understand as this is a relatively new approach, but that doesn’t mean you shouldn’t advocate for what’s right for your child.)

As for professionals, I encourage us to reflect on the messages we send parents and children about persistent oppositional defiance. When we insist that a child can overcome these challenges “if only she puts her mind to it,” the message takes a heavy toll on the child and on her relationships.

And what about Stuart, who struggled so much as a child? His devoted parents eventually placed him in a supportive day treatment program. There, he came to understand something that had been his constant companion since infancy: a persistent and unrelenting fight-or-flight response that would virtually take over his body from time to time. With that new perspective on himself, he was able to begin to rebuild emotionally, and move forward with his life.

I describe how providers across disciplines can support the emotional lives of children in my new book, Social and Emotional Development in Early Intervention.

I invite you to comment, join my newsletter and my Facebook page, where I post helpful resources for parents and professionals.

  • Karen H

    Thank you

    • mdelahooke

      My pleasure, thank you for reading..

      • Lauri A Daily

        Does ODD continue into middle age?

        • mdelahooke

          Well that’s a good question. It’s primarily something observed in childhood, but I think it might take different forms in adulthood. Many different scenarios including resolving but also persisting into other mental health challenges are possible, if not properly addressed and supported.

  • scoutinfp

    This is very interesting. I feel like social anxiety disorders and selective mutism are also disruptions of this system, but in those cases, it’s the freeze or flee response that is being triggered, rather than the fight – which it seems like you are saying is happening here. This makes alot of sense to me. This may be a stupid question, but if this is the system that is being triggered, would beta blockers possibly help?

    • mdelahooke

      I agree that many other disorders may be linked to these disruptions–the list may be endless, with variations of the fight, flight or freeze response. My colleague Connie Lillas has named another response, which she calls the “combo zone” which includes a rapid cycling between shut down and fight or flight. Lots to think about. Your question about beta blockers is an interesting one. I’m not a physician so I can’t speak to it officially, but I think there may be a risk in tampering with feedback systems.. The best bet clinically is to improve attuned, engaged, and loving relationships surrounding the individual.. I’ll have to ask Dr. Porges this question next time I see him! Thanks for commenting.

  • Excellent article, Mona. How very important to stop blaming both children and parents for “out of control”, “oppositional” behavior and instead get to the underlying causes. Even when we are able to get children (and adults) to comply with behavior management, they may continue to experience high levels of stress in their bodies. They may look like the serene duck floating on the water, but they are “paddling like hell underneath”. Which has both short-and long-term implications for adverse health. Thank you for your unique understanding and strong voice!

    • mdelahooke

      Deborah thank you so much for validating how important it is for us to look at underlying causes. I love your illustration of the duck in the water! So so true, what we don’t see is often how desperately hard children are “paddling” inside! Thank you for your insight!

  • Pat Kline

    My son has been diagnosed with schizophrenia, but ODD was included in the list of his issues. It makes sense to me that the ODD has been a symptom of his reality breaks, rather than its own issue. Thank you so much for helping me understand.

    • mdelahooke

      So glad it was helpful, Pat. Wishing you and your son well.

  • Teri Ann Muldoon Snedaker

    Simply, thank you. I have been feeling so ???, I done even know. Inadequate I guess. Our poor guy is so angry and defiant for usual no understandable reason. This give us a new perspective.

    • mdelahooke

      I”m so glad! Thanks Teri..

  • Rita La Voie-Clarke

    This has really been an eye opener for some one near and dear to me. Unfortunately, his family won’t listen so maybe I’ll just have to give him the info. Thank you.

    • mdelahooke

      I hope it’s helpful at some point!

  • Kristy Bodkin

    Where does one start with a 12 year old? Is the book more focused on early years? My son has no diagnosis, but his behaviour has a direct impact on ALL of his relationships (and mine). The information above is a pretty good match. We have a cycle of needing him to reach a blow out before he can regroup and recover. There’s little chance of him regulating without . It’s an exhausting pattern.

    • mdelahooke

      Yes, I hear you. The book is focused on early years, although the the social and emotional milestones are developmental and not based on chronological age. Finding calmness and security in relationships is difficult for some children, and my book explains why… wishing you the best..

    • Tashja Janzen

      For me I try to get my little guy to recognize and own his behavior. Not as a discipline,but to empower him. We talk openly about mental health and meds so he can grow up not feeling embarrassed. I don’t try to talk while he hates me for pouring rice Krispies when clearly I should have read his mind and poured the mini wheats lol. After school when he is happy to see me I will ask him if we can talk. I have to start fresh everyday..even when it’s been 3 weeks straight of difficult days. I let go of the little things. I taught my kids to meditate and do deep belly breathing, it has been amazing for them. They feel empowered being able to bring themselves down to a manageable state. It can be exhausting..but they are all such beautiful little souls.

  • Janyce C. Johnson

    And what do you do at nearly 19yo when ODD is now called Mood disorder NOS, Borderline Personality Disorder, meds are barely taking the edge off and everything is a non preferred activitiy so potential trigger

    • Kitty Kavanaugh

      Mood journal, attend DBT, coping skills and I recommend video games as an activity and way to practice coping skills. Meds only work to allow person the chance to use their skills.

    • mdelahooke

      Hi Janyce, such a good question and makes me wonder if he had/has misunderstood stress responses. I think that’s why this article is getting shared so much. My profession has largely missed the mark on how to treat ODD. It’s complicated. I recommend the website and you can look up mental health professionals –you may be able to find someone in your area who uses a relationship-based developmental approach. Most important is to have a treatment team you and your son have confidence in, and where he feels valued and understood. I also recommend the parent book No Drama Discipline by Tina Payne Bryson and Dan Siegel. Wishing you and your family the best.

  • Just shared. Understanding “perceived” threats are just as real to the brain as “actual” threats. Seeing misbehavior as an unmet need. Asking ourselves “What’s the need?” in the face of challenging behavior rather than “What is wrong with you him/her?”… these small shifts in our homes and school have the power to bring so much peace and healing, ODD or not. This deconstruction has far reaching implications for all parents and educators, whether they are dealing with ODD or not. I’m most especially thankful for your paragraph on the pitfalls of discipline rooted solely in behavior management. As a parent educator, I’ve seen this single revelation shift entire homes. THANK YOU.

    • mdelahooke

      Thank you for sharing and for your thoughts, Suzanne! I have also seen the positive shift that happens. It’s so hopeful and has the potential to strengthen relationships that are so strained under the pressure of these very confusing and challenging behaviors. Thank you so much for commenting and best wishes in your work as a parent educator.

  • Juliette Colet

    Super interesting. Helps to change perspective. Thank you.

    • mdelahooke

      Thank you Juliette.

  • Senshin

    My son has been diagnosed with ODD. We have tried every approach we could find and nothing has helped. All the traditional approaches seems to have made things worse. He doesn’t react violent all the time, like I’ve heard about other kids with the same diagnosis, only once in awhile. He seems to be more cunning: planning revenge, planning how he can upset everyone the most, eavesdropping, pretending he can’t do things in order to get our of chores, pretending he can’t hear or remember and so on. The doctor said his high intelligence makes him react different from other kids with ODD. She said he simply feels he’s too smart to do the things he’s asked to do and he likes to find ways to outsmart everyone. He does not respond to privileges being taken away or given, to being left alone if he can’t be nice, to us being very very consistent in our discipline, giving rewards and so on. What I’ve read in your new book makes sense to me. But I was wondering how stealing, seeking revenge, never ever taking responsibility and having no compassion towards others fits into it all? Thank you.

    • mdelahooke

      Thanks for commenting, and your observations of your son are part of the complexity behind these types of diagnoses. I can’t comment on specifics, other than to say I’ve heard many of the same descriptions from parents as what you mention here. It sounds like you have a dr. who is trying to help you understand the reasons underlying the behaviors which is so important. I urge you to continue to look for newer approaches that will hopefully help. You might find some good tips on the website or parent toolbox at Wishing you the best! And I’m writing a parent book that will have more examples and parenting tips in it. Take care!

  • mpainter

    Thank you! Thank you! Thank you! I’m devouring your articles this evening and saying, “YES! FINALLY!!! That’s it!” Your articles are like reading about our son and our experiences! I cannot thank you enough for having eyes to see this “disorder” for what it really is. With a degree in education, I knew all the “tricks”, tried all the “tricks”, researched/problem-solved new “tricks”, and none were working consistently or predictably with our 4th son (we have 5 sons, with our 4th being the only one with this persistent and unrelenting and unpredictable flight/flight response since early infancy). In this singular evening reading your articles, I’ve gone from defeated and near hopeless after 8 years of confusion and feelings of helplessness with our son to hope-filled and looking forward to approaching his fight/flight responses in a new way that is best for equipping him to “connect-the-dots” to hopefully improve his short-term and long-term emotional well-being! I look forward to reading your book!!! Truly, thank you more than words can express!

    • mdelahooke

      Thank you for letting me know, and taking the time to comment. Even though what I am talking about is not mainstream yet, I hope that it will be soon. And if you feel more hopeful in this journey, then I have succeeded in my main goal: hopefulness and the healing power of relationships. And while my book is written for professionals, as a parent, you will get the idea about the paradigm shift in how we see challenging behaviors (chapters 3 and 6). I”m beginning a book for parents this summer. Wishing you all the best!

  • Suziqoo

    More helpful actions would be appreciated.

    • mdelahooke

      Thank you! I have a new post on the way with more actions. Actually, I will be writing many posts on the topic since there is so much to unpack and so many aspects to support and treatment.

  • Kacie Morgan

    I can agree with certain points in the article regarding the lack of understanding from many professionals and their explanations of ODD and understandings of ODD, but at the same time here there are a few things that should be discussed. Stress reduction techniques, tools in a tool box etc these are all forms of behavior management so many professionals believe in trying to give these kids with ODD but the question becomes what happens when a kid won’t use those techniques? For many children with ODD its not just their flight/fight response that kicks in but also their interpretation of reality in many cases it highly skews to the point that many feel they have done nothing wrong in situations even when they act aggressively even to the point of physically harming themselves or others how to you change someones version of reality? Certain aspects of the models do help. For example sticking to the rules, making sure that consequences and expectations are clearly outlined in writing and followed. Why does this help with some? With some it will help take arguing out of the equation because its written down clearly, its posted for all to see, its not changed at random, its a piece of reality that logically can’t be debated it also helps reduce stress for some so there is no misinterpretation tbrough communication. The idea of scheduling reduces stress for many because the child knows what is coming next esp eith abuse victims. It doesn’t work for all as not all need that. Lumping in and saying however that odd needs stable loving relationships but that assumes that many parents aren’t providing that safe relationship…its fairly rude to assume that as a cause of stress. Many children from homes without abuse or distress have other diagnosis besides ODD which take years to diagnose and on top of that many times misdiagnosed. As I’ve stated many have a twisted viewpoint on reality this can and in many cases includes feeling loved even when a parent expresses love… I agree that ODD is not something to be cured, its not a disease, its a set of behaviors labeled as a disorder because of all of the different possibilities that are needed for treatment…but mostly because you can’t help a flawed reality you can’t force someone to use tools and techniques but most of all you can’t lump that all treatments work for all people. Heck many withb ODD could qualify as having narcissistic tendencies but since that is a normal part of adolescent phases nonone labels it that way but I’m guessing some do become narcissists. The real question is what is the difference between those that go on to lead normal adult lives and those that don’t.

    • HeroineKy

      Excellent reply!

    • mdelahooke

      Hi Kacie,
      Such good observations. When kids won’t use techniques or tools given them, when their interpretation of reality is skewed (as it often is), and when the child has come from a stable, loving home; this is when the concept of faulty neuroception helps to explain the confusion. I describe in my original post on ODD.
      I believe that those who do well have providers and caregivers who understand how to calm this subconscious challenge in threat detection. It also explains why some kids have trouble accessing the help they so desperately need. To me, that’s the difference between those who thrive through this diagnosis and those who continue to suffer. Thanks for commenting!

      • Kacie Morgan

        Ok I’ve read that post as well, and could see for some how that would fit esp in autism spectrum disorders. However, most kids with ODD from stable homes fit into 3 categories: are completely aware what they are doing is wrong and can’t help it, the flip side where they don’t see the actions as wrong and the middle ground which is where most of your articles focus is which is the kid that doesn’t want to be blamed for doing something wrong knowing they did something wrong. Mostly what connects all three categories are 1. Other mental issues from adhd to schizophrenia. Which most Dr.s won’t say or tell parents. 2. Poverty which causes lack of access to competant and appropriate and affordable care services as well as appropriate testing for mental health issues.
        3. Lack of understanding of social changes of our society to a fear based society and the consequences as such.

  • drdanj

    The mot important part of this is the NIMH defunding of research based on DSM categories. That’s huge. I’ve always objected to the DSM checklist model as circular reasoning, a tautology A+B+C=X=A+B+C. There is no external referent. It is also wildly culturally loaded, and allows for no context, normal responses to abnormal environments, and oh so very much a middle class model of mental health.

    • mdelahooke

      I so agree. That tautology gave the incorrect message to therapists that the checklists were a roadmap to treatment. Looking at underlying causality, and taking context, cultural considerations, and survival mechanisms that humans use (which are adaptive but can look maladaptive on simple DSM checklists) is much more important! I think
      the NIMH made a good decision there.

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