The Self-Reg View of: “Diagnosing” Oppositional Defiant Disorder

The Self-Reg View of: “Diagnosing” Oppositional Defiant Disorder

Click here to download this article as a formatted PDF.

I had just finished a long morning session and was stopped on my way out by a woman in obvious distress. She told me her 8-year-old son had just been diagnosed with Oppositional Defiant Disorder (ODD) and she didn’t know what to do. Would Self-Reg help him? Would Self-Reg help her! The answer to both questions was, of course, “Yes,” but there was something about what she’d said that I found deeply troubling. It’s that ominous word “diagnosed.” I find it deeply troubling every time I hear the same thing – and believe me, I’ve heard it more times than I can possibly recount.

In reality, her son had been subjected to the same sort of procedure that animal control officers use to identify a dog breed. Say an officer has to determine whether a particular dog is a pit bull. He uses a checklist, and a dog is considered to be a pit bull if it possesses five out of eight characteristics [Identifying a pit bull]. Similarly, the little boy in question had been found to meet five of the eight behaviours used to diagnose ODD. That is, he had received a tick beside:

  • Often loses temper
  • Is often angry and resentful
  • Often argues with authority figures or adults
  • Often actively defies or refuses to comply with requests from authority figures
  • Often blames others for his mistakes or misbehavior

But in what way is this a diagnosis? Certainly not in the sense in which the term was originally intended, which, following standard medical usage, was supposed to refer to “the process of finding out what is causing a certain set of symptoms” [Diagnosis]. Each demands an immense amount of careful thought. So to truly help such a child, we need to begin by asking “Why?” after each item.

But there is a further problem here. Think about how emotionally charged the very name “pit bull” has become. How differently it would feel to look at, say, a checklist for “toy poodle.” So too, with words like “oppositional,” “defiant,” and “disorder.” Without our realizing it, our attitude is being shaped and our thinking guided by the very terms used. Just hearing these words is enough to set your teeth on edge: enough to shut down the sort of “reflective stance” needed to do a proper diagnosis. For true diagnosis has to be nonjudgmental and grounded, not just in knowledge and experience, but also a profound sense of uncertainty [The Reflective Practitioner]. But this little boy, like so many others, had experienced nothing of the sort. In a very real sense, his “treatment” had been determined by the name of the disorder.

That is not to say that the symptoms grouped together here are without significant meaning. On the contrary, what is particularly important about this cluster is the the telling combination of mood and behaviour problems. Yet that still leaves us with the crucial question of what exactly it is that this is telling us. That is most certainly not a question to be dismissed; rather, it too needs to be diagnosed!

Perhaps the first thing we need to do is get rid of the label. My children’s pediatrician, Dr. Till Davy, once told me that really we should be talking about these behaviours as angstbeisser and I instantly thought: what a great term that would be! For one thing, no one would know what it meant, which would enable us to bypass all the biases that are summoned up just hearing the words “oppositional,” “defiant” and “disorder” all used together. For another, “angstbeisser” refers to the actions of a cornered animal that lashes out in order to protect itself, which points us in a very different direction. But protect itself from what? From us?

That, as Dr. Ross Greene has explained, turns out to be the critical issue [Ross Greene]. ODD is really a dyadic phenomenon: a consequence of the belief that the first duty of parents is to “socialize” their child: i.e. help, or, when necessary, force their child to acquire skills or traits that do not come naturally – and a lot less naturally for some children than others. According to this view, when parents fail to perform this role it’s because their child is suffering from, among other things, low frustration tolerance, poor emotion regulation, reduced communicative skills, and heightened impulsivity, together with – and in some cases even caused by — permissive parenting.

The thinking here is that if the child’s “oppositional tendency” is not corrected, he will be at risk of developing an even more serious disorder (e.g., anti-social behaviour, depression, addiction) [ODD as Predictor]. So better a course of “tough love” now than these negative downstream consequences. Yet what Self-Reg sees is a child or teen who is already suffering: caught up in a maladaptive coping strategy in which, as was highlighted in the earlier DSM-IV entry for ODD, “parent and child bring out the worst in each other.” [DSM-IV]

Why “maladaptive”? The reason lies in the critical role of Social Engagement as a child’s first line of defence for dealing with excessive stress [Porges on Social Engagement]. A child needs adults to help him cope with stresses that he cannot manage on his own. “Angstbeisser” is maladaptive not just because it undermines Social Engagement, but because such behaviour actually increases the child’s stress load by eliciting a hostile and possibly punitive adult response.

But, while it may seem as if the child is choosing to be oppositional, we have to ask: why would any child ever choose to stress himself even further? The fact is that, far from being volitional, his behaviour is driven by paleo-mammalian and reptilian mechanisms that trigger primitive “defensive” behaviours and suppress those communicative and inhibitory skills that the child is commonly seen to be lacking. So the more oppositional the child, the more an adult must react in the opposite way – i.e., counter-regulate – in order to re-establish Social Engagement. Yet such a response is widely seen as a form of weakness rather than a biological imperative of the Interbrain.

In other words, the standard view of “Oppositional Defiant Disorder” results from a “cognitive blinder” in the sense defined by Ellen Langer [mindfulness #1]: a dysregulation of Social Engagement that is the result of excessive stress (caused by any number of factors) coupled with a cultural bias that leads adults to mistake expressions of anxiety for acts of defiance and demand submission instead of providing solace. The very term “Oppositional Defiant Disorder” is an expression of the deeply entrenched self-control mindset that shapes our perception of children’s behaviour and accordingly our responses [self-regulation vs self control infographic].

In some ways, what we’re really dealing with is an “Oppositional Authority Disorder,” although even that way of stating the matter is overly severe. For the truth is that it can be very hard not to see a child as oppositional when they dig their heels in. We become terribly anxious ourselves. No doubt we could tick “parent” versions for each of the ODD criteria boxes. There is “limbic resonance” at play (this is fully explained in [Self-Reg]), not to mention the importance we attach to whatever is the source of the conflict. But on top of that there is the added stress that stems from the “ODD bias.” It is this added stress that leads to a battle of wills in which everybody loses. Even if one of us gets our way we both lose, both in the immediate moment and over the long term.

As is always the case with Self-Reg, our first step is to “reframe”: to consider what may be linking the symptoms clustered together. Some are “internal” or trait-based and others are “relational.” It is the connection between them that is critical: specifically, the child’s inability to navigate the relational world with adults, which is exacerbating his arousal. There is nothing intentional or even conscious about this, and we cannot help the child by assuming otherwise.

A big part of the challenge is that children who demonstrate these symptoms invariably have a negative bias. This has profound implications for how they see adult overtures: how they interpret a look, tone of voice, facial expression. Whatever the cause of their negative bias, they are primed to see even the most innocuous of gestures as a threat. To compound the problem, adults all too often go straight for the child’s PFC, harping on “choice” or “taking responsibility.” When a child is on full alert, that simply adds to the threat level.

Instead, we need to confine ourselves to right-brain to right-brain co-regulation. Don’t ask questions, and certainly don’t lecture – much less punish or harangue. We need to go into full-out soothing mode, bearing in mind that it can take quite a long time before a child’s alarm turns off – which, of course, is a defining feature of “allostatic load” (this too is explained in [Self-Reg]). To help such children we have to stay with warm, comforting vocalizations and looks, and avoid the temptation, as the child starts to calm down, to “seize the moment” to talk about how he’s expected to behave. That moment will come! But first the child has to be well and truly calm, and there is simply no way of saying how long this might take for a particular child.

Dr. Davy’s point was that what we are really seeing with children with ODD “is the role of anxiety coming out as opposition and defiance.” It’s a hugely important point. How different would our attitude be if we referred to this cluster as a distinctive behavioural sub-type of an “anxiety disorder”? For that is what it is, and that is why this cluster of symptoms is important. How differently would adults have seen and engaged with this little boy? How different would that mom’s own emotional state have been had she understood, not just that she needed to do Self-Reg, but much more importantly, why.

And how differently that mom would have felt had her son received a proper diagnosis: a surge of hope and relief as opposed to anxiety and distress. But for that to be possible we need an entirely new vocabulary/mindset. To start with, we need to replace:

  • “Oppositional” with “anxious”
  • “Defiant” with “hyperaroused”
  • “Willful” with “maladaptive”
  • “Disorder” with “dysregulated stress cycle.”

And we need to ask ourselves: How did we lose our compassion for children? For it is that quality that lie at the heart of true diagnosis. Without it we’re just ticking off boxes.


Dr. Stuart Shanker is the Founder and CEO of The MEHRIT Centre.  You can read all the posts in his “Self-Reg View of” series here. You can also read his writing on Psychology Today and The Huffington Post.

By | 2018-01-26T14:27:56+00:00 June 5th, 2016|

11 Comments

  1. Laura June 6, 2016 at 6:33 pm - Reply

    Great Blog Dr. Shanker- it is creating a lot of discussion at our not-for-profit today with families.
    We may have a coffee chat around this blog and we posted it on Facebook.
    Thank you!

  2. Marilyn September 16, 2016 at 6:15 pm - Reply

    This is so powerful. This is the second time I have read through this and it will not be my last.
    Thank you!

  3. Marie Eroh December 13, 2016 at 7:35 am - Reply

    Suggestions on how to get this book in the United States?

  4. […] The Self-Reg View of ‘Diagnosing’ Oppositional Defiant Disorder by Stuart Shanker: A gentler view of a daunting ‘diagnosis’, and a look into how Self-Reg reframes the ODD labeling of children. […]

  5. Adrienne Sweat January 22, 2017 at 3:47 pm - Reply

    I’m definitely of the persuasion that ODD only exists as a diagnosis because of our compliance-obsessed authoritarian society. I much prefer your vocabulary replacements.

  6. Roth February 28, 2017 at 10:50 am - Reply

    This DSM- IV category is something like a nightmare: counterproductive in any way you can think about. Beside that there is something resonating in society. I think there is a change in society which leads to such forms of conflict. For sure it is part of a stress response because children, parents and also teachers are often in a stress cycle. I think there are much more phenomena involved. As families are living more and more isolated there is no backing of an extended family or community. There is a lack of community of adults and (!) children in the way of cooperation and building up things. Looking only through the lens of individualism you end only at the concept of competition. If you are lucky and somehow successful you can be pride, for the rest there is only the hidden message of shame and the effort to get rid of this negative emotion by knowing it all, being aggressive and playing a bully part. This is also true for teacher and parents, not only for children. As it is mainly a taboo to talk about weaknesses the sad story of hiding instead of reaching out to get help, compassion and support begins. I would like to ask what kind of strategies, practices “we” can offer to down-regulate shame for the whole system which includes parents, children and their teachers (emphaty often doesn’t work in such cases, when the level of shame is too high). I am reading an impressive book about this issue from Uri Weinblatt “systemic mirroring”, but the perspective is too limited and focused on the therapeutic approach which is in my view not broad and applicable enough. In contrast to “our” personal experience to-days middle class children are supported in a way which is totally new in human history. Maybe in contrast to thinking in terms of low self esteem there might be a feeling of an unrealistic high self esteem as result of this support which is in constant danger to be confronted with the normality who we all are.There is no place for imperfection, because anything has to be good and good is never enough. The question is therefore in my my view how to create an atmosphere of cooperation and compassion (which are collective experiences) where every children can find a place not only in the peer group and also how the adults can trust and learn from each other and how we can create a culture of appreciation of mistakes and differences. I have a wonderful quote from a wonderful guy Keith Johnstone living in your country saying “Be average” https://www.youtube.com/watch?v=bz9mo4qW9bc. Is this a dream ? Could we imagine an average school with ordinary vulnerable people ? or do we always say we are special, very special and totally special ?

    My best wishes for your wonderful project

    • Stephanie Pellett March 6, 2017 at 5:34 pm - Reply

      Hi Roth, thanks for your comment! Here was Dr. Shanker’s answer:
      What a wonderful response. The author takes the argument to what is undoubtedly a critical level of modern cultural values and their impact on psychological wellbeing and, interestingly, performance. I just finished watching the TEDx talk by Keith Johnstone and would strongly recommend this to all: especially the section towards the middle called “Be Average.” I have just ordered a copy of Maximum Performance.

      • L. Cubas April 12, 2018 at 2:03 pm - Reply

        Who is the author of Maximum Performance?

  7. Barbadosbelle October 11, 2017 at 3:32 pm - Reply

    Often loses temper
    Is often angry and resentful
    Often argues with authority figures or adults
    Often actively defies or refuses to comply with requests from authority figures
    Often blames others for his mistakes or misbehavior

    I don’t think that I’ve known any child EVER who hasn’t displayed all of these five behaviour issues listed, at some time or another. Goodness know what the other three are.

  8. Bill Reynolds January 19, 2018 at 12:53 pm - Reply

    Stuart,

    Very powerful message here with such practical help. Thank you so much for this and for all the untiring work you do in the field to bring true compassion to our children and parents.

Leave A Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.

X