If I were to choose a single word that best characterizes these 2 disorders it would be irritability. All children become irritable at one time or another during various phases of their growth and development, but irritability that exceeds what is generally expected for a child’s developmental age may be an indication of an underlying mental disorder. When a mental disorder presents with irritability as one of its primary symptoms, determining the correct diagnosis can be a clinical challenge. Accurate diagnosis then, shapes important diagnostic, prognostic and treatment implications.
Oppositional Defiance (ODD)
The core of oppositional defiance consists of 3 primary domains:
- Anger; rage; irritability
- Argumentative, defiant behavior
- Spiteful, revengeful behavior lasting at least 6 months
In addition, the child often loses his or her temper which progresses into rage, accompanied by refusal to follow rules, commands, and directions. ODD is multifactorial in that it’s linked to a combination of bio-psycho-social factors.
Disruptive Mood Dysregulation Disorder (DMDD)
Central to a diagnosis of DMDD is the presence of chronic, unremitting, non-episodic irritability that is:- Present before age 10 years
- Occurs in two or more settings (severe impairment in one setting and mild to moderate impairment in a second setting)
- Has been exhibited for at least 1 year
This irritability manifests as frequent, severe temper outbursts that typically occur three or more times per week, usually secondary to frustration, and may result in aggression toward others. In addition to temper outbursts, the child is irritable or angry most of the day, most days of the week. Most children who meet diagnostic criteria for DMDD also meet diagnostic criteria for oppositional defiant disorder. However, in addition to emotional outbursts, children with DMDD also will have mood symptoms (which are not characteristic of children with oppositional defiant disorder) and are more significantly impaired. I’d best describe DMDD as oppositional defiance on steroids.
The most important first step in achieving behavioral improvement in children and adolescents with ODD or DMDD is to establish a safe setting and a stable environment for the affected child, because without safety and security, there will be no ensuing positive behavior.
Control is a major factor when working with ODD and DMDD. Kids are often given too many choices when it comes to managing their behavior, overwhelming them and causing even more distress, so the most efficient and powerful way to provide control is to create an atmosphere of safety. Too many behavioral approaches fail because there is not enough work done on the front end to identify why the behavioral is happening in the first place. Also, what motivates the child to continue the behavior is poorly understood – thus there are few, if any, proactive measures within programs or systems such as teaching social skills, coping and problem-solving.
Parents are often a part of the problem, while they must be a major part of the solution. They often lack bona fide parenting skills, talk and explain too much, cajole and nag their kids to change their attitude and disruptive behavior. They’re also inconsistent and focus more on telling their child what not to do, as opposed to explaining what to do. Responsible parents must take on the role of co-regulator of the child’s behavior, and in doing so, must be appropriately regulated themselves.
Here are my top 7 behavioral strategies for youth with ODD or DMDD:
- Allow the child to earn privileges. Children and adolescents are much more likely to do what is expected when they have the power to earn something, than when being threatened that you will take something from them.
- Use empathetic statements. “I know you’re really enjoying your computer time and you don’t want to turn it off, but you need to get rest for school. You can have some time on the computer again tomorrow.”
- Phrase directives in a positive way and eliminate the word “can.” For example, instead of “stop jumping on the furniture,” try something like “sit down” or “come down off the couch” in a calm, but confident tone. If possible, provide an alternative activity or redirect them to something they like to do such as “let’s do jumping jacks together” or “here are some puzzles to play with.”
- Use specific praise. “Excellent job picking up your toys,” “you were so focused during homework tonight,” “nice job listening to directions” etc. Specific praise reminds the child what behaviors you are looking for and reinforces them.
- Offer choices. “Do you want to wear the green or red shirt?” “Do you want to do your math or reading homework first?” “Do you want to set the table or take out the garbage?”
- Say only what you mean, and mean what you say. Stay away from empty threats (punishments that you will never follow through on). The child will come to learn the value of your words. If you don’t mean what you say, they won’t take you seriously.
- No lectures, monologues or sarcasm. Once your rules are in place and the child is aware of them, state them as needed. If your child starts to argue after you have stated the rule and given empathy, let them know that you are not going to discuss it anymore. Never give in to a tantrum.
Taking collective responsibility, making connections, and providing safety are where it all starts with youth displaying disruptive behaviors. We must remember that challenging children are still just children, and that in spite of how difficult they can be, many of them – through their inappropriate actions – are telling us “please look past my behavior, it’s not who I really am.”
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.