Julie M. Milne is a Licensed Clinical Professional Counselor in practice at the Counseling Center, Lutheran General Hospital, Park Ridge, IL.
Jeffrey K. Edwards is a Professor, Department of Counselor Education, Specialization in Family Counseling, Northeastern Illinois University, Chicago, IL
Jill C. Murchie is a Licensed Clinical Professional Counselor in practice at the Counseling Center, Lutheran General Hospital, Park Ridge, IL.
This work was supported through the funding of a graduate research assistant by the Graduate College, Northeastern Illinois University, Dr. Mohan R. Sood, Dean.
Oppositional Defiant Disorder affects and is affected by the families, school systems, social services systems, medical systems, law enforcement, the community, and those individuals exhibiting and classified as having this problem. The treatments of Oppositional Defiant Disorder are many and varied, leaving one wondering at the cause and treatment options. The prevalence of Oppositional Defiant Disorder is examined in this paper, the various models of treatment are reviewed, and an integrated family systems strength-based model is presented.. In keeping with suggestions for family systems meta research, the model's parts have proven track records of producing positive outcomes with Oppositional Defiant Disordered children and their families. It is postulated that the effect of placing these parts together will have a synergistic and cumulative effect of treatment, increasing positive outcome with this population.
In the fall
of 1995, the three authors came together concerned about the increased
violence in youth reported in our respective school systems, communities
and nationally (Snyder, Sickmund, Poe-Yamagata, 1996; Mediascope, 1997).
Edwards having worked with youth in residential facilities, and Murchie
having taught in "BD" classrooms, had experience with children who had
been diagnosed by the medical and psychological communities as having Oppositional
Defiant Disorder (ODD).
The literature
states that children exhibiting ODD symptoms are at high risk for developing
later problems with aggression. It is reported that these children often
misjudge others' actions as more hostile than they really are and overreact
to situations (American Psychiatric Association, 1994 & Barkley, Anastopoulos,
Guevremont, & Fletcher, 1992). Research shows the "disorder" impacts
not only the children's social, academic and family relationships, but
if left untreated, as many as 75% of children struggling with ODD develop
Conduct Disorder, Antisocial Disorder, and other adult psychopathologies
where aggression and violence and lack of remorse are part of the diagnostic
criteria (Long, 1996).
The authors
decided to investigate ODD, focusing on family systems treatment methods
that might prove helpful in providing change and relief to those involved.
A survey of previous research investigating the effects of family therapy
netted some practical parameters, but earlier models did not specify ODD
as a focus of treatment. Gurman and Kniskern (1981) have pointed out that
the comparative study of two or more treatment methods is useless unless
a specific patient population has been well defined." Pinsof and Wynne
(1995) have suggested that "in order to develop a coherent body of scientific
knowledge about the efficacy and effectiveness of marital and family therapy,
it is particularly critical at this point in the field's evolution to focus
as much as possible on specific problems and disorders" (p. 341). Taking
these parameters seriously, we have narrowed the focus specifically to
one clearly defined "disorder."
We were particularly
interested in how we might use postmodern, constructivist approach to work
with families and youth struggling with the aggressive behaviors often
found with Oppositional Defiant Disorder (ODD). Our approach incorporates
several ideas from postmodern therapies. The postmodern movement in counseling
has been shouldering its way into mental health for the last ten years.
In a nutshell, the movement has its roots in phenomenology, constructivism,
social constructivism (Guterman, 1996) and epistemology. Postmodernists
believe that there is not one true view of a problem, its etiology, meaning,
or solution, but instead see numerous competing viewpoints. Viewpoints
differ based on social interaction, gender, culture, language structure,
and socioeconomic context. There are many viewpoints about Oppositional
Defiant Disorder, its definition, etiology and how to help families and
children struggling with ODD. There is no quid pro quo solution or technique
for postmodern family therapists working with those who fight against ODD.
There is an endeavor to find out what works in each specific (client) situation,
rather than attempting to fit situations and problems to some theoretical
frame, thus psychopathology is seen as political rather than as medical
reality. People are not the problem, the problem is the problem. Postmodern
counseling is utilitarian and contextual and considers constructivist,
narrative and solution oriented therapies as methods of helping clients.
In any case, these therapies have at their core, a strength-based, as opposed
to a deficit-based, focus. Thus, we are calling our framework Strength-Based.
Edwards and Chen (1999) have suggested that "Within the last decade a competency
or strength-based approach has emerged, departing from the medically modeled
tradition that focuses on assessment of deficits or problems."
Like Michael
White, the authors of this paper believe that using labels such as Oppositional
Defiant Disorder "steals the uniqueness from a person" (White as cited
in Pipher, 1996, p. 123). However, the medically modeled view of ODD exists
in the larger sociopolitical discourse. Thus, it is important both to the
therapist and family to have some understanding and background as to how
the medical system and managed care view ODD.
Oppositional
Defiant Disorder (313.81) is a medical term used in the Diagnostic and
Statistical Manual of Mental Disorders-IV (APA, 1994) used to describe
children, who exhibit a recurrent pattern of negativistic, defiant, disobedient
and
hostile behavior toward authority figures that persists
for at least 6 months and is characterized by the
frequent occurrence of at least four (or more) of the following behaviors:
loosing temper, arguing with adults, actively or refusing to comply with
the requests or rules of adults, deliberately
doing things that will annoy other people, blaming others
for his or her own mistakes or misbehavior, being touchy
or easily annoyed by others, being angry or resentful, or being
spiteful or vindictive. To qualify for Oppositional Defiant
Disorder, the behaviors must occur more frequently than
is typically observed in individuals of comparable age and
developmental level and must lead to significant impairment
in social, academic or occupational functioning (e.g.
son/daughter, student, friend, sports team player, etc.).
The criteria
for Conduct Disorder are not met, and if the individual
is age 18 years or older, the criteria are not met
for Antisocial Personality Disorder (APA, 1994).
Appendix A is a tool based on the DSM-IV criteria that can be used to assess for ODD.
Depending on
the reference or research one reads, ODD occurs anywhere between 2% to
22% of the school age population (APA, 1994; & Applied Medical Informatics,
Inc., 1997). The medical model literature reports that the "disorder" is
more prevalent in boys than girls and onset typically becomes evident before
eight years old and not later than early adolescence (APA, 1994; Applied
Medical Informatics, Inc., 1997; Long, 1996). Comorbidity rates as high
as 65% exist between ODD and Attention Deficit Hyperactivity Disorder (ADHD)
and they incorrectly are sometimes confused as one and the same (Barkley,
Anastopoulos, Guevremont, & Fletcher, 1992; Biederman, Newcom, &
Sprich, 1991).
Many of the
ideas, definitions, and etiologies about ODD presented by the medical model
and early family therapy theorists, focus on individualism, competition,
and power or one-upsmanship over the client, ideas postmodernists challenge.
Yet, it is important to be aware of these ideas.
It is always important for those in any field of study to be familiar with theory and practice in the development of that field. When it comes to treating ODD, naturally, we as authors would be remiss if we did not include a survey of the various ways the development of behavior problems like ODD have been theorized. However, we have a clinical as well as academic motive for understanding the differing etiologies of ODD. Coming from a postmodern viewpoint, the authors believe it is important that our clients also be able to consider various perspectives and determine which ideas make sense in their situation. To do this, a therapist must be able to present the pros and cons of various models (or ideas about the etiology) of ODD. This gives the clients an internalized "reflecting team" so that they might have multiple perspectives of ODD from various "professional" points of view. Therefore, an early step in the treatment approach we have developed is to empower the clients with knowledge about different theories that have been constructed about the development of behavioral problems such as ODD to see if any "fit" with their situation.
If there is a medical cause for ODD, it is unknown at this time. Oppositional Defiant Disorder is a relatively new medical diagnosis which seems to be in a state of evolution. Oppositional Disorder first appeared in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) under the heading "Other Disorders of Infancy, Childhood and Adolescence." Seven years later, in the DSM-III-R, Oppositional Defiant Disorder (ODD) was introduced as a separate disorder from Conduct Disorder (CD) and Attention Deficit Hyperactivity Disorder (ADHD) under the heading "Disruptive Behavior Disorders" (Ferguson, Horwood, & Lynskey, 1994). "Swearing" was eliminated from the criteria for diagnosing ODD in the DSM-IV as was the general heading "Attention Deficit and Disruptive Behavior Disorders," (APA, 1994, Frick, Lahey, Applegate, Kerdyck, Ollendick, et al, 1994, & Lahey, Applegate, Barkley, Garfinkel, McBurnett. et al, 1994). A few of the medically or physiologically related theories being investigated are:
1. A predisposition to ODD is inherited in some families.
2. There may be neurological causes.
3. ODD may be caused by a chemical imbalance in the brain (New York Hospital-Cornell Medical Center, 1997).
The medical literature reveals that several studies associate ODD and/or its symptoms with maternal depression and psychopathology, marital discord, parental alcoholism (Reich, Earls, Frankel, Shayko, 1993; APA, 1994), lack of parental attachment (Crittendon, 1990 & 1992), and children who have suffered abuse (Barkley, Anastopoulos, Guevremont, & Fletcher, 1992). Most of these correlations between family issues and ODD or the development of problem behavior have been addressed in the following family theories.
The ideas of family therapists have evolved from the early works of systems theory and cybernetics, and have been steadily moving to a model that utilizes languaging and postmodern ideas. What all of these models have in common, however, is the notion that problems or dysfunctions do not reside within an individual as is believed by those who adhere to medically oriented model, but are better understood by viewing the contributions of parts of the system.
Early Family Therapy Models
Early family therapists noted the correlation between the development of problem behavior (the term ODD was not yet in common use) and a variety of family-related factors. Using the language and ideas of their particular era, each of the following reflects a particular perspective in the etiology and treatment of behavior disordered children.
Communication
family therapists. Bateson, Jackson, Haley,
& Weakland, (1956) were excited by the emerging field of cybernetics,
"a science dealing with the comparative study of complex electronic calculating
machines and the human nervous system in an attempt to explain the nature
of the brain" (Webster's New World Dictionary, 1968). These theorists noted
that families, like mechanized automatic control systems, had predictable
patterns of receiving information and processing it, forming their own
kinds of feedback loops. These theorists began looking at disordered behaviors
in children as resulting from persistent, disturbed patterns of communication
in a family system. For example, a child's current poor academic achievement
could be seen as a defeated reaction to persistent parental messages implying
failure and disappointment for any grade less than 100%. Rather than helping
their child aspire towards excellence, such parental communication could
in fact be helping the child conclude that since a 45% and a 95% were met
with the same response, there was little point in trying for the 95%. That
is, the child translates "How could you get such a poor grade?" and "What
happened to the other five points?" as "I'm a failure unless I get 100%."
The child's problem behavior in this case would be a direct result of a
persistent, disturbed pattern of communication.
John Weakland
(1976) expanded this cybernetic-based communication theory to include behaviors
as well as language. He suggested that problem behaviors (not just words)
in the family system functioned to maintain behavioral disorders in children.
His goal, then, became that of changing problem-maintaining behaviors,
thus interrupting a vicious feedback loop.
At its core,
communication theory regarding the etiology of problem behavior is quite
linear, i.e., that parents' irrationality causes children's behavior disorders.
The influence of this perspective can be seen in a 1982 publication entitled
"The Oppositional Child." It states that "Oppositionalism appearing early
in elementary school is nearly always due to maternal pressures. When it
appears for the first time in high school or college the father is usually
the one who is responsible" (Brahan, 1982, p.10).
Behavioral
family therapists. Patterson and Reid (1970) agreed that both communication
and behavior strongly impact a child's behavior. They noted that this influence,
however, not only operated from parent to child, but that it also operated
in a reciprocal manner from child to parent. Children, like parents, develop
patterns of reinforcement and extinction which exert controlling effects.
Thus, the behavioral family theorists saw the etiology of problem behavior
as residing in the interaction between parent and child. The goal of treatment
(Gurman & Knudson, 1978) was to address the problem-maintaining behavior
as an interaction to which both child and parent were contributing. Using
classic behavior modification techniques, these therapists worked to increase
the rate of rewarding interactions, decrease the rate of coercive and aversive
interactions, and teach more effective communication and problem
solving skills. Again, the influence of this perspective can be seen in
later research. Research by Barkley, Fisher, Edelbrock, & Smallish
(1991) suggested that the development and maintenance of ODD into adolescence
in hyperactive children is strongly associated with negative parent-child
interactions (communication and behavior) in childhood.
Structural
family therapists. Structural family therapists believed that behavioral
problems are rooted in an imbalance within the family structure. For them,
behavioral problems resulted from inflexible family structures unable to
adequately adjust to developmental or environmental challenges or stressors.
When there is an imbalance in the family's hierarchical structure (either
too punitive or too smothering) and a lack of differentiation between the
subsystems (Nichols & Schwartz, 1995), structural therapists aim to
help the family alter its existing structure so that the problems being
faced can be solved.
Most important
of the overall goals is to help the parents regain or maintain their position
in the hierarchy as superior to their offspring and to function as a cohesive
executive subsystem (Madanes, 1981). Thus, when a child in a family is
acting out, a structural therapist would want to check out the alliances
in the family. If Mom and child are more closely aligned than Mom and Dad,
the structural therapist would first seek to realign Mom and Dad into an
executive team, thereby differentiating the parental and offspring subsystems.
A structural therapist would further assess the system for parenting styles.
Baumrind (1989) suggests that "authoritative" parenting, which offers affection
and support along with reasonable limit-setting and negotiation of differences,
promotes a healthy balance between independence and connectedness.
Strategic
and systemic family therapists. For strategic and systemic family
therapists there are three basic explanations for the development of behavioral
problems: (1) problems persist because of misguided attempted solutions
which only exacerbate the problem; (2) problems are the result of confusion
in a family's hierarchy or boundaries; and (3) problems are the result
of people trying to indirectly protect or control one another, with the
behavior serving as a means of preserving homeostasis in the system (Nichols
& Schwartz, 1995). Similar to behavioral family therapists, strategic
family therapists assess observable patterns of behavior. They then work
towards problem-resolution by helping change the behavioral responses people
have to their problems.
Bowenian
therapists. One last theoretical framework from the earlier models
deserving mention is that of Murry Bowen and his followers. For them, behavioral
disorders, mild or severe, can be seen as the result of emotional fusion
transmitted from one generation to the next (emotional fusion being the
opposite of individuation). In this rather complex view, each person in
a family is viewed as experiencing anxiety to the degree that he or she
has not yet differentiated from the family "ego mass." Until a parent's
ability to manage his or her own anxiety is addressed, handling their child's
behavioral problems may be overwhelming. By fortifying the parents' level
of emotional functioning, through increasing their ability to operate by
differentiating from their own families of origin (Kerr & Bowen, 1988),
Bowenians set a context for dealing with behavior problems in the child.
To this end, extensive use of genograms and exploration of family myths
and patterns are often used in the course of therapy. Behavior problems
are thus seen as best understood in the context of family heritage.
Ideas regarding
the etiology of ODD are not explicit in any of the five family therapy
perspectives described above. As noted earlier, ODD as a term wasn't in
use during the time periods in which much of the seminal work of these
theorists occurred. However, ideas about the etiology of behavior disorders
in children abound throughout the literature. These ideas, in turn, have
found their way into a variety of settings, not only among therapists,
but into the assumptive world of much of America's population at large.
Before the
work done by earlier family therapists, behavior disordered children were
often seen as separate from their families, and referred to as "black sheep,"
"rebellious," or even "just plain bad." Early systemic work was very helpful
in recognizing that an I.P. (identified patient) was likely carrying the
symptoms of many family members. Working with the system, whether in terms
of its communication patterns, interactions, structures, problem-solving
strategies, or heritage, created useful interventions and the reduction
of many previously problematic symptoms.
Recent Family Therapy Models
The following
perspectives are largely articulated by Post-Modern and Constructivist
therapists. Because ODD is by definition saturated with "negatives," we
have found it especially helpful to remind ourselves that the basic components
of any strength-based treatment are also crucial to a successful approach
to dealing with ODD.
Unlike much
of the literature and past family systems theories, the authors tend to
agree with more recent family therapy theory which sees neither the parent
or the child as the "problem." Instead, we see the family system itself
as part of a larger system. In America, for example, there is a culture
or ecosystem that has strong components of individualism, aggression, and
power over others. A family system may be struggling against external forces
from the larger ecosystem leaving both the parent(s) and the oppositional
child feeling disempowered as they try to maintain their own family system
in the context of the larger system which may not be supportive of their
values. The more recent family therapy theories take into account the diversity
of the cultural context and seek to empower families to find their own
goals and solutions from within the family system itself. Examples of family
systems theories that empower the family in the context of the larger ecosystem
are collaborative therapy, narrative therapy, and solution-focused therapy.
Constructivist
therapists. Anderson and Goolishian (1992), and Hoffman (1993), introduced
a collaborative conversational approach where the therapist comes from
a not-knowing position, the client is the expert in languaging his story,
and the two collaborate to create a narrative metaphor. The client is empowered
to change his future. Like these theorists, we believe that the meaning
derived from the language used in the stories comes from the socio-cultural
or ecosystem in which the client lives (McNamee & Gergen, 1992).
Narrative
therapists. White and Epston (1990), and Freedman and Combs, (1996)
also use collaboration in their work. They also externalize unwanted behaviors
instead of pathologizing and internalizing them. They have a narrative
emphasis to their work. Both collaborate with the client and family to
restory their narrative about the family's successes with trampling out
the ODD behaviors and to retell it to others in their ecosystem such as
relatives, teachers, and peers to make the story their own.
Solution-focused
therapists. de Shazer, (1991) and his
followers developed the concept of the client and therapist collaborating
to find solutions and exceptions to the problem that have worked or might
work, and setting clear goals and strategies to achieve the solutions,
so that therapy can be brief. Problems are not discussed, only solutions
(Nichols & Schwartz, 1995).
All of the
aforementioned recent family therapies would have in common, the belief
that the child and family and their social systems co-construct through
language the perception of the problem and those behaviors that accompany
the problem.
Oppositional
Defiant Disorder is currently a collection of symptoms without a clear
etiology. There is not yet a medically determined cause. Social/environmental
factors considered by early family therapists (for behavior disorders in
general) resulted in a variety of proposed etiologies, including family
communication patterns, interactions, structure, problem-solving techniques,
and heritage. More recent post modern and constructivist theorists, aware
of the tremendous diversity within modern society, have wrestled with the
reality of a larger system in which each family system seeks to find its
own place. Rather than focusing on etiology, these theorists have developed
models for empowering the family system within the context of the larger
ecosystem. Solutions are seen to reside within the family system, with
the goal of "minimizing the client's dependency on the therapeutic relationship
and maximizing the client's resourcefulness and self-sufficiency in more
confidently and effectively moving along the road of life" (Friedman in
Hoyt, 1994, p. 218). Therapists such as Michael White and David Nylund,
while not developing specific protocols for working with behavioral disorders,
have numerous case studies in which their approaches are seen to work as
well in families struggling with ODD as with any other behavioral challenge
(White & Epston, 1990; Smith & Nylund, 1997).
It is the
view of these authors that because ODD has multiple etiologies, and exists
within the context of a diverse, pluralistic cultural context, counselors
will need to be familiar with a variety of techniques and perspectives,
choosing from among them those strategies which best apply to a given situation.
To that end, we have developed what we are terming "strength-based treatment
approaches." By strength-based, we mean a perspective which looks for strengths,
successful strategies and solutions that arise from within the family.
We define "approaches" as therapeutic perspectives, evaluation considerations,
and a variety of treatment techniques, and use the term "approaches" to
clearly differentiate what follows from a linear, medically modeled treatment
protocol.
Figure 1 illustrates
the conceptual model which we are using to organize our strength based
treatment approach. The figure is adapted from a change model developed
by William Bridges (1991). The model consists of three strands which are
always present, but in differing proportions: old reality, alternate possibilities
and new reality.
From the moment
a client enters therapy, all three strands must be ever present in the
mind of the therapist. Even though strand A (old reality) will likely be
proportionately larger in the initial session where the family and therapist
seek to understand the meaning of the problem (ODD), there must be a conscious
effort to open up new possibilities leading to a new reality. The length
of time that a client or family spend on any one strand will be highly
variable depending on previous experience, motivation for change, and interference
or support from the larger ecosystem.
Strand B (alternate
possibilities), which is a time of transition during which alternate possibilities
are considered, becomes more prominent as therapy progresses. While focusing
on strand B, there is still the awareness of the original problem (strand
A) and an emerging awareness of new realities (strand C).
As therapy
comes to completion, possibilities explored (strand B) crystallize into
new realities (strand C) and new behaviors are becoming stabilized. The
presence and memory of the former reality (strand A) still exists, and
alternate possibilities (strand B) keep emerging, but the new reality (strand
C) has taken hold.
Our strength-based
treatment approaches, which we are organizing by means of this conceptual
model, are intended to fit in many types of settings – youth programs,
school counselors, agencies, hospitals, etc. Any mental health professional
can determine which of the strength-based approaches will best fit the
client and family at any given point during therapy. Professionals charged
with affecting behavioral changes will be able to look at this model and
determine the proportionate balance between the three strands for the client,
the support systems, and the therapist, him/herself. He or she can then
choose appropriate strength-based approaches for the situation.
When we consider the notion of "therapeutic stance," we are referring not to the content of a session or treatment approach, but to a frame of mind. This frame of mind needs to continue across all strands of our conceptual model. There will never be a time when we are NOT consciously aware of taking the "One-Down" position, paying attention to the client's language, externalizing the problem, and helping the client create a new story.
Assuming a "One-Down" Position
One of the stances we take in strength-based therapy is to remove the traditional status given to therapists as being all knowing. Like other post modern therapists we believe that one-up position undermines and demeans the client. In this postmodern context the therapist and client join as equals both bringing resources to the therapeutic relationship to collaborate to help the client develop knowledge and skills to move beyond the current crisis, e.g. the ODD behavior patterns.
Paying Attention to Language
In addition to valuing what is learned by assuming an attitude of "not knowing," we agree with those therapists who have emphasized the importance of paying attention to language. As each member of a system, (teacher, social worker, parent, grandparent, child, family friend, etc.) describes his/her experience, in this case with ODD, he/she is creating part of the meaning of ODD for them. Part of being empathic and giving validity to each person's story is to take note of the language they use, and to use their words or phrases when reiterating or verbalizing understanding their story.
Externalizing the Problem
An important part of working with ODD, as with any other challenge, is to recognize that the child is not the problem. The problem is the problem. The purpose of externalizing the problem is to provide a separation between the child and the problem which allows the child and family to create preferred ways of relating to the problem (White & Epston, 1990). For example, children might be asked if they know why they have come to therapy and what concerns their parents (teachers, coaches, etc) have. These concerns, loosing temper or actively refusing to comply with rules of adults, might be spoken of from the first session in an externalizing manner. For example, "It sounds like your teachers are concerned when "temper" and "defiance" are around. The externalizing conversations are continually used throughout therapy to help children separate their sense of identity and personhood from the problem at hand and to empower them to take a stance against the problem (ODD behaviors).
Restorying
We mention
restorying here as a therapeutic stance because we believe restorying,
like the other concepts mentioned in this section, is also a way of thinking.
We agree with White and Epston, (1990), and Freedman and Combs (1996) that
part of the task of therapy is to collaborate with the client in both deconstructing
the past and co-constructing a future. This collaboration begins from the
moment we first encounter a client, and is communicated in our every gesture,
movement, and word. It is a stance of possibility and hope.
The above
Strength-Based contributions of more recent family therapy theorists are
ones we recommend as forming the foundation of a therapeutic stance in
working with children and adults impacted by ODD behaviors. More basic
than techniques or treatment plans, they form the philosophical base for
our Strength-Based approaches. They are ways of thinking, and of being
with the client and all those impacted, that are embodied throughout the
whole conceptual model.
Suggested Therapeutic Techniques Within the Framework of the Conceptual Model
As stated before, at this point ODD has no clear etiology. Every case will need to be evaluated on its own, and the therapist will need to make therapeutic decisions based on that particular case. In order to bring a little more structure to the therapeutic techniques which follow, however, we have organized techniques according to the strand in the conceptual model where that technique is likely to be especially helpful (Figure 2). Keep in mind that the model itself assumes all strands are present at all times, varying in proportion depending on the progress in therapy.
STRAND A: "OLD REALITY"
The dominant task of the therapist, regardless of the proportional balance between Strands A, B, and C at any point of treatment, will be to understand every possible facet of the impact of ODD on the client, family, and larger system. The impact of ODD will likely vary considerably from person to person in terms of understanding, experience, and notions regarding etiology. The following techniques are ones we have found especially useful in the process of deconstructing the old reality. Appendix B is a tool the therapist can use to remind him/herself of suggested techniques to use with the parent(s) and child.
Cross Questioning.
Cross questioning occurs any time person A is asked what he or she believes
person B would say in response to a particular question. In couple's therapy,
cross questioning is used when a therapist asks one partner, in front of
the other, to express what the other partner's perspective might be. In
this case, both people are present in the room.
Cross questioning
as a technique, however, needn't be limited to couples work. Children can
be asked what their parents would say, and parents can be asked about what
a child might say. We often start a first session with a child by asking,
"What has your Mom told you about why you're here" instead of asking the
parent that same question directly.
A variation
on this theme is to ask Person A what they think Person B would say, even
if Person B is not in the room. For example, suppose argumentative behaviors
during family dinners are a problem. No one else from the family may be
in the session at the time, but as a therapist you can elicit another family
member's perspective by asking, "If your Mom were here right now, what
would she say is happening when arguing is present during dinner?" "What
would she say is happening when arguing isn't occurring?"
Revealing
the Cast of Characters. The child identified with ODD symptoms never
lives in a vacuum. It is important, therefore, to intentionally discern
all the players in the child's system and their contributing thoughts regarding
etiologies. In a typical scenario, the child him/herself, parents, siblings,
school, social service workers, peers, extended family members, etc., will
each have a perspective, often differing, and likely expressed regarding
how Johnny got "this way." As the cast of characters and their beliefs
are revealed, the therapist will become familiar with those persons in
the system who might be supportive of moving into the alternate realities
(Strand B), and who will need more time to move out of the Old Reality
(Strand A).
Use Scaling
Questions. In addition to exploring differing beliefs between members
involved in the system, it is helpful to get a clear picture of the intensity
members might have regarding a particular idea. Scaling questions are useful
in determining the level of intensity perceived by the cast of characters.
Clients are asked to rate, on a scale of one to ten, one being least, ten
being most, their perspective on a particular issue, i.e., how serious
they consider specific behaviors to be, opinions regarding a particular
etiological idea, and the amount of effort required to actualize future
change. This subjective information gives the family — all of them — clearer
understanding of where they each stand in regards to this dilemma. Many
times, family members are baffled by the differences in their scaling one
from another. For instance, in one family where a 16 year old girl and
her family were asked how problematic they perceived her temper tantrums
to be, the girl was surprised and somewhat flabbergasted that her sister
and parents rated her temper tantrums a nine while she only rated them
a six. As level of intensity is clarified between the various members of
a system, the Old Reality (Strand A) forms a baseline from which alternate
possibilities (Strand B) will be developed.
STRAND B: ALTERNATIVE POSSIBILITIES
Uncovering
the beliefs about the old realities helps the members of the system begins
to realize the diversity of perspectives between them. This in turn lays
a ground work for members of the system to consider opening up new realities.
As the proportional balance between the Old Realities and the Alternative
Possibilities begins to shift we have found the following techniques especially
useful.
Resourcing
Additional Perspectives to Open Up Alternative Possibilities. Holding to
an unassuming perspective does not exclude the therapist's contributing
new information to the system. One of the reasons that clients come to
us as therapists, is that they hope that we can help them move beyond their
present position. Holding to an unassuming position is maintained in the
manner the material is presented. We therefore find it helpful, in some
cases, to present from our own knowledge base ( i.e., existing , and sometimes
conflicting research, theories , experience, etc.) additional perspectives
for the family's consideration. This new information is presented not as
our definitive evaluation or direction, but rather as a means of opening
ideas for alternate possibilities. As families begin to sort out these
new perspectives, identifying those that have particular meaning in their
situation, alternate possibilities begin to emerge.
Finding
Exceptions. Strength-based approaches have at their core the notion
that there are times or situations during which the problematic behavior
does not occur. When working with ODD, it is useful to ask the child, or
other important members of the system, about times when the child has been
able to win out over their struggle with the ODD behaviors. The child and
family are asked to expound on these exceptions. What was different then,
and what is different now? This also allows the family to begin to see
that the child has, in the past had times that were different from the
problem-saturated situation, and that in the present, there are also times
when he/she can push away the ODD. These exceptions are used by the therapist
to provide the child and family with alternate possibilities. The child
is not the problem, the behavior patterns are the problem. They are external
to the child. This restorying gives the family hope. As Pipher (1996) has
suggested, therapists can see the courageous struggles clients make, and
have the power to give them hope. Therapists can teach them to be empathic,
flexibility, tolerant and respect diversity in our culture, and help families
connect with their extended families and others in their communities.
Surveillance
Game. In addition to exploring alternate conceptualizations, it is
important while working in Strand B to note alternate behaviors. The surveillance
game technique is one that can be applied to any number of situations or
desired behavioral outcomes.
In this game,
also called the "secret game" for young children, parents (and any other
members of the system) are asked to secretly do something positive for
the other between sessions. They are instructed not to tell each other
what they have done. In the following session, all those playing the game
are asked to guess what they did for each other. The objective of the game
is that system members begin to focus on each other's positive behaviors
and communication instead of the negative. Often several positive behaviors
are noted before the intended behavior is correctly guessed.
Redefining
the Hierarchy. Hierarchy consists of two dimensions: a "soft" side,
which includes showing empathy, respect, fun, good times and good things;
and a "hard" side, which concentrates on rules, limits, consequences, decision-making,
goals and protection from harm. In short, those in authority need to provide
both nurture (the "soft" side) and structure (the "hard" side) for those
in their care (Clarke & Dawson, 1989).
We have noticed
that in families, as well as in school and other field settings, it is
common for members of the system to split these two dimensions, with various
members holding either the hard side or the soft side. In school settings,
for example, classroom teachers, tired and dealing with many children,
are often aware of disruptive behaviors, and become very structured in
response. In the one-on-one setting of the school counselor's office, the
child is often more cooperative, and the counselor demonstrates the more
nurturing side. When all members of the educational system are present
in a staffing, these splits between the hard side and soft side of the
hierarchy are often apparent. Similarly, we also often notice a similar
split between mothers and fathers.
Often parents,
teachers, or case managers, in their frustration over ODD behaviors, find
themselves caught in a "structure only" hierarchical stance. They have
long since stopped allowing themselves to enjoy the child. They tend to
feel guilty if they provide any nurturing activities, and fear that any
expression of even kindness might be "rewarding the child for bad behavior."
Just as unproductive in dealing with children exhibiting ODD behaviors,
is a fearfulness of setting down limits and boundaries. In those cases,
it appears that system members are afraid to "be mean" or "vindictive",
and so avoid establishing clear boundaries and consequences. In either
case, highlighting a system member's stance, and redefining hierarchy as
a gift to children which incorporates both sides, can sometimes open up
multiple alternate possibilities. Depending on the age of the child, use
of the surveillance game can be helpful at this point.
Tagging.
Oppositional children seem to enjoy the challenge of a duel. Conventional
wisdom dictates that when a child violates established boundaries, the
issue should be settled immediately, not saved for a later time. With oppositionally
inclined children, this strategy does not seem to work.
"Tagging"
is a technique whereby when oppositional behavior begins to occur, the
parent (or teacher, etc.) notes the behavior verbally — "tagging" it as
it were. Then the parent says "I'd like to discuss this at a later time
when both of us can be calm." End of discussion.
Interrupting
an oppositional cycle before it escalates does several things. It keeps
tempers and actions at a low level. It doesn't allow for the child to pick
the place for a tantrum, demanding attention away from others (such as
leaving for a social event, interrupting dinner, or taking attention away
from a sibling). It provides care givers time to decide on a course of
action, rather than impulsively handing out consequences. And it teaches
a child to develop self-control.
This technique
is one which parents and teachers alike often embrace with relief. It opens
up more enjoyable interactions, and seems to generate alternate possibilities.
It provides a means by which care givers are not held hostage to a child's
outbursts, and allows the adult to be in a position of determining the
outcome.
Each of the
ideas and perspective presented above are part of the process of generating
alternate possibilities. In a system which has been problem saturated,
we begin to offer and co-construct new behaviors and new views and ways
of relating that are more satisfying. As these behaviors and attitudes
begin to change, members of the system often find themselves free to develop
an increasing respect for each other. These Alternate Possibilities (Strand
B) become New Realities (Strand C) for parts of the system.
STRAND C: NEW REALITY
In the conceptual
model that we have proposed, there will always be an awareness of old realities,
the generation of alternate possibilities and emerging new realities. It
is the proportion between these three strands which changes over the course
of therapy. It is important to note that the proportion between the three
strands will likely differ for different parts of the system. For example
family members who have been working hard may begin to see changes. The
school principal who has less contact with the child, may be more lagging
behind this perspective. Often one family member will catch the vision
for a different way of living and serve as a trail blazer for other members
lagging behind. Some members of the system believe that change can happen
and they can be part of the process.
Supporting
the New Reality. In Strand C the primary goal is to integrate the new
realities into a supportive community. Research has shown that when children
have more supportive assets from the community, they have fewer at-risk
behaviors. When alternate possibilities and new realities have been identified,
an important part of the model is to call or write teachers, principals,
scout leaders, etc. to share the positive information about the child.
Often this will be the first positive information that these people will
have received about the child. The effect of hearing or reading this new
reality about the child is that they will gain a new perspective about
the child, begin looking for the described behaviors, hopefully reinforce
the positive behaviors, and the family will gain their cooperation in helping
the child create the new life story. We also encourage such members of
the supportive community to provide positive feedback back to the child
and his family as they see new realities begin to take root in a variety
of settings. Naturally, it is important to ask children for their permission
before calling or writing others.
How you support
the new realities depends on the developmental level of the child. For
example, certificates of accomplishment are very effective with younger
children while a supportive letter from a peer may have more meaning for
an adolescent girl. Ask the children who in their peer group, relatives
or community supports their new realities and ask their permission to request
that these people write them letters or send them e-mail about how they
perceive the changes in their behavior.
Our current
thinking believes that the use of peer groups for adolescents would be
more effective than individual therapy alone. It seems that it would be
more responsive to the developmental needs of this age group.
The Strength-Based
Model for Treating Oppositional Defiant Disorder is an attempt to integrate
several existing models into an updated postmodern framework. To date,
it has been field tested with only a few cases from our independent practices.
The parents seemed to benefit especially from the use of concepts, e.g.
empathizing with them over their struggles with their children rather than
blaming them for producing "dysfunctional children," presenting multiple
views of ODD, and redefining hierarchy and its two component parts. Focusing
on exceptions, playing the surveillance game and enlightening other members
of the family's ecosystem about the children's strengths have all demonstrated
success in working with these children combating ODD. But our work is as
yet anecdotal.
As far as
etiological concerns, today, in working with a family struggling with ODD
we question if the ecosystem, family or otherwise, is communicating that
the child is not achieving their expectations. Is the ecosystem placing
such pressure on the child to attain our culture's highly valued state
of individualism, e.g. being team captain, being number one in the class,
etc., that the child and family has lost sight of the child's positive
qualities and the value of connecting to others? Does the language used
by the ecosystem encourage or discourage positive self esteem in the child?
When a child can't be number one and stand out among all his/her peers
in the manner the ecosystem expects, is acting out and troublesome behavior
the only way the child sees himself being an individual, being successful,
getting attention? Families need to be encouraged to find the uniqueness
in each child and to strengthen those unique possibilities through positive
communication or languaging techniques. A story from an anonymous author
will demonstrate what we mean.
Whenever I'm
disappointed with my spot in life, I stop and think about little Jamie
Scott. Jamie was trying out for a part in a school play. His mother
told me that he'd set his heart on being in it, thought she feared he would
not be chosen. On the day the parts were awarded, I went with her to collect
him after school. Jamie rushed up to her, eyes shining with pride and excitement.
"Guess what Mom," he shouted, and then said those words that will remain
a lesson to me: "I've been chose to clap and cheer."
Author unknown.
We have seen anecdotally the benefit of using a model that avoids the blaming stance of the traditional medically modeled treatment of ODD and views families as the cause. We further believe that the protocol needs to have more direct and verifiable research in order to show its efficacy and effectiveness. As stated in the beginning, researchers have indicated the need for specific treatment models to be "context specific and/or problem specific," (Pinsof & Wynne, 1995a; Gurman & Kniskern, 1984). We believe this protocol to have the elements needed for a field protocol; one that would be useful in multiple settings, e.g. schools, agencies, and residential treatment centers. It is our belief that this work can be useful in helping to eliminate the behaviors the American Psychiatric Association define as Oppositional Defiant Disorder.
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Figure 1. Strength-Based Conceptual Model
Figure 2. Suggested Therapeutic Techniques Used in the Conceptual Model
Complete the following information.
Child's age_____________
Child's developmental level (Erickson)__________________________________________
Place a check mark next to all the behavioral descriptions that the child exhibits in social, academic or occupational (son/daughter, student, friend, sports team player, etc.) settings and specify the length of time (days, weeks, months or years) each has occurred.
Behavior Length of Time Occurring____
_____ Looses temper ________________________
_____ Argues with adults, actively or refusing to
comply with their requests or rules ________________________
_____ Deliberately does things that annoy others ________________________
_____ Blames others for own mistakes or
misbehavior ________________________
_____ Is touchy or easily annoyed by others ________________________
_____ Displays anger or resentfulness ________________________
_____ Displays spiteful or vindictive behavior ________________________
_____ Total number of checks
**To qualify for the DSM-IV definition of Oppositional Defiant Disorder, the child must exhibit four or more of the above behaviors, the behaviors must persist for at least six months, and the behaviors must occur more frequently than is typical of children of a comparable age and developmental level. The child must be younger than 18 years old.
According to the medical model/DSM-IV criteria, this child exhibits behaviors that show he/she is struggling with Oppositional Defiant Disorder. _____ Yes _____ No
Place a check mark next to all tasks that have been accomplished, and give a rating as to your perception of your success and it's effect (1 low – 5 high). Model assumes a nonblame stance and attempts to address how difficult it has been for all. In order to do that: