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 likely 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 (oppositional, defiant) 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 is open to the idea that oppositional behavior can have a variety of causes. 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 behaviors, emotions and sensations underlying the behavior. For example, some professionals are not aware of a biological cause of sudden serious behavioral shifts, caused by an unusual reaction to a strep infection, known as PANDAS: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Bottom line: Continue to seek professionals who have a wide lens, and solutions beyond simple behavior management.
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, and over time, he was able to begin to rebuild emotionally, and move forward with his life.
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