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When Defiance Isn’t Just Disobedience: A Clinician’s Guide For Parents · Inside The Consulting Room - Understanding the Child Behind the Behaviour

• 0:00
  SPEAKER_00: Welcome back.
• 0:00
  SPEAKER_00: This is Kim Lee, child and adolescent psychotherapist, and I want to spend some time talking about different kinds of disorders that children may be experiencing.
• 0:15
  SPEAKER_00: But I think the the motivation for doing this is twofold.
• 0:20
  SPEAKER_00: The first is that when when we see behaviors that we don't understand, we wonder and sometimes assume that they represent illness or some kind some kind of disorder.
• 0:38
  SPEAKER_00: And as a clinician, I quite often experience people saying, My child is suffering from, and I ask whether the child has been diagnosed, and quite often people will say yes by Dr.
• 0:54
  SPEAKER_00: Google, which may which may be accurate.
• 0:58
  SPEAKER_00: But on the other hand, as clinicians, we think about differential diagnosis, and what that means is that we think about well, here we have a presentation of symptomatic difficulties, how do we understand them?
• 1:12
  SPEAKER_00: And because we have a greater understanding of a range of difficulties, we sometimes conclude, well, yes, it might look like that, but to me it sounds more like you know something else.
• 1:27
  SPEAKER_00: And sometimes what we'll do is ask for a second opinion, because what we want to do is to ensure that the child and family have the right help.
• 1:39
  SPEAKER_00: So today I want to talk about oppositional defiant disorder, what it actually is and what it isn't, and to see if that in some way helps to frame understanding.
• 1:55
  SPEAKER_00: Now the truth is many children will argue and many will resist and many test limits.
• 2:03
  SPEAKER_00: But that's not oppositional defiance disorder, because that condition isn't really ordinary disobedience.
• 2:14
  SPEAKER_00: It's defined as a persistent pattern of angry, defiant, hostile, and vindictive behavior directly towards authority figures, which has been evident for at least six months and significantly impairs functioning and relationships.
• 2:37
  SPEAKER_00: Now, the manual from which this knowledge comes is called the DSM, which is the diagnostic statistical manual, and the version five is the most current.
• 2:52
  SPEAKER_00: That's the fifth edition.
• 2:55
  SPEAKER_00: And the the diagnostic criteria within that manual is important.
• 3:00
  SPEAKER_00: And it states that what you're looking for is a pattern of angry and irritable behavior, argumentative behavior and so on, for at least six months, with at least of at least four of the following symptoms that or expressions.
• 3:20
  SPEAKER_00: So that angry, irritable mood is one category, and that describes the child often loses their temper, is often touchy or easily annoyed, is often angry and resentful, that they're argumentative in and defiant, that they often argue with authority figures, often actively defy or refuse to comply, and often deliberately annoy others.
• 3:49
  SPEAKER_00: And they often blame others for mistakes or behaviour, misbehaviour.
• 3:55
  SPEAKER_00: There is also a theme of vindictiveness, and that they have been spiteful or vindictive at least twice in the past six months, and that the behavior must occur with someone other than a sibling and must cause clinically significant impairment in social, educational, or family functioning.
• 4:20
  SPEAKER_00: I think the reason that distinction is made is because within the context of the family, such behaviors may be seen in a different in a in a different way.
• 4:35
  SPEAKER_00: But when they occur in other settings, what you start to see is because different unspoken rules apply, the failure to acknowledge and to respond to the sort of unspoken or spoken rules provides a slightly different dimension.
• 4:55
  SPEAKER_00: And this is particularly relevant because what's happening psychologically is it's not just bad behaviour.
• 5:03
  SPEAKER_00: It's a disorder of emotional regulation and authority processing.
• 5:08
  SPEAKER_00: Frustration tolerance, which is a really interesting term, which it was utilized in the early 90s to describe an aspect of the child or young person's functioning, that the frustration tolerance was noticeable by its absence.
• 5:29
  SPEAKER_00: But what also may be happening psychologically is attachment or relational trust difficulties and autonomy versus control conflicts.
• 5:40
  SPEAKER_00: So what we see is that the child is often locked in a power struggle, not because they want power, but because they feel powerless.
• 5:48
  SPEAKER_00: So defiance often masks as anxiety, shame, sensitivity to criticism, fear of failure, loss of control, and sometimes deep unmet emotional need.
• 6:01
  SPEAKER_00: And what we see there, of course, is that when that is the case, the central nervous system becomes hypersensitive to those things that feel shaming, abandoning, in some way demeaning, unrecognized, and neural pathways formed which then trigger unregulating or unregulated emotional states.
• 6:26
  SPEAKER_00: And you one will always see that in such children emotional regulation is clearly underdeveloped.
• 6:36
  SPEAKER_00: And developmentally that will be for a number of reasons, and that includes things like when parenting becomes coercive or inconsistent, where the child experiences chronic frustration or invalidation, and and where there are neurodevelopmental vulnerabilities such as ADHD, ASD, autistic spectrum disorder, and of course we can't rule out the effects of trauma.
• 7:02
  SPEAKER_00: So the behavior becomes a relational pattern, not just a symptom.
• 7:07
  SPEAKER_00: Now in the next episode, we're going to look at what causes ODD, the biology, the temperament, attachment, and environment.
• 7:21
  SPEAKER_00: Now, from the point of view of being a parent of a child with this difficulty, it is important that you are equipped to understand how it's put together, as well as how to deal with the behaviours that arise and the tremendous strain that places on others.
• 7:44
  SPEAKER_00: Parents quite understandably really don't know what to do.
• 7:56
  SPEAKER_00: Very often, because of that lack of knowledge, situations become self-maintaining and can be very difficult.
• 8:05
  SPEAKER_00: I've worked with a number of children who are presenting with the symptoms of ODD, and in my experience, then they're explicable because either they are called a co-occurring difficulty, that there is something else going on, some other kind of psychological difficulty or disorder, and that the ODD symptoms are expressions of that, or there are other what I call what are called environmental factors, and the experiences that the child has sustained which have resulted in this symptomatic expression.
• 8:44
  SPEAKER_00: So we're going to look in subsequent episodes at those things as well.
• 8:51
  SPEAKER_00: I think the the final thing I want to say for this first episode is that we can't diagnose children with any kind of disorder as parents.
• 9:05
  SPEAKER_00: We can have hunches, we can we we can do some looking around and we can be curious.
• 9:12
  SPEAKER_00: But diagnosis is a very specialized task and and it's very important because what that does is to point towards what we need to do.
• 9:24
  SPEAKER_00: Sometimes people will make the mistake of thinking that diagnosis is a label.
• 9:30
  SPEAKER_00: Well, I suppose it can be used in that way, but as a clinician, my view is that a diagnosis is the necessary stage that we have to reach before we can treat.
• 9:44
  SPEAKER_00: This is why every patient that I see undergoes clinical assessment, because I want to be as clear as I can be about what's going on, in order that I can approach it with the best possible outcome in mind.
• 10:00
  SPEAKER_00: And that of course includes parents.
• 10:04
  SPEAKER_00: So I will post the next episode soon, and that will be about the causes of oppositional defiant disorder, and as we progress through the series, we'll look at a variety of other things.