Life with a Pathologically Defiant Child
This is a journey no family would choose, and the outcome is unclear even under the best of circumstances. Here is one boy’s story.
By September 4, 2018 - last reviewed on May 14, 2019published
Before Oscar* got kicked out of his first preschool, he was upset about lunch. Not long into the school year, the 4-year-old expressed his displeasure with the midday meal by dousing his tray with milk. When his teacher brought him to the director's office to be disciplined, Oscar was unrepentant. He reached his tiny arm across the director's desk and swiped its contents onto the floor.
It was already clear to his mother, Sarah, that something was off. Oscar's tantrums were nuclear; his disobedience was beyond correction. And he was so impulsive that when someone else's child climbed into a gorilla cage at the Cincinnati Zoo, Sarah was seized by terror—and sympathy. Given the number of times Oscar had broken free from her at the zoo and run off in search of adventure, it was sheer luck that he hadn't ever landed in a cage himself.
Now 14, Oscar has been diagnosed with oppositional defiant disorder (ODD) and severe attention deficit hyperactivity disorder (ADHD). He still throws tantrums when he doesn't like what's on the lunch menu. But when he runs off now, he sometimes comes home in a police car. His behavior is more self-destructive than criminal, but it tends to attract attention.
Once, when Sarah took her kids—Oscar and his older brother plus their two younger sisters—grocery shopping, Oscar decided he'd had enough before Sarah had gotten through her list. She urged him to be patient. Instead, he ran to a nearby dollar store, where he raged to a clerk that he was going to kill himself by drinking bleach. The clerk called the police, and Oscar ended up in a children's hospital, where he was involuntarily committed as a suicide risk.
Kids like Oscar are regulars in hospital mental-health wings. They're also overrepresented in after-school detention halls and juvenile justice centers—and, when they grow up, in jails and prisons. We see them on the news when they do something dramatically reckless, like climbing into a gorilla's cage—or when they commit an act of violence. The recent wave of school shootings has brought aggressive, impulsive young offenders to the forefront of public consciousness.
So how do we keep explosive kids from becoming destructive, dangerous teens and adults? Armchair parenting experts tend to promote harsh punishment, arguing that even the most challenging kids will straighten up if given significant consequences for their actions: a good long grounding, say, or a strategic spanking. Many of us shake our heads at the overly indulgent parents who, we believe, allow their kids' behavior to escalate unchecked.
But research reveals that, contrary to conventional wisdom, harsh discipline backfires when it comes to pathologically disobedient kids. The best way to keep them from ending up on the nightly news is, instead, a skill-building, problem-solving approach grounded in compassion.
Experts in the so-called disruptive behavior disorders—which include ODD and conduct disorder, and which often accompany ADHD—say that instead of doling out punishment, we need to help these kids develop the coping skills and impulse control that aren't innate to them.
"It's only counterintuitive if you haven't been paying attention to the research that's accumulated over the last 40 to 50 years," says child psychologist Ross Greene, who founded the nonprofit Lives in the Balance, which advocates for changing the way we treat behaviorally challenging kids. "And that research is pretty compelling."
Oscar lasted all of a week at his second preschool. The kids were expected to take an afternoon nap, or at least to lie down quietly. He refused. And it wasn't just nap time that irked him; he refused to do any of the school activities. He'd simply get up and run away. Sarah enrolled him next in a preschool designed for kids with special needs, but they couldn't handle him either. Neither could the fourth one, which specialized in "difficult" kids. He was too much, even for them.
So began Oscar's journey from school to school. His explosive tantrums and "flight risk" status closed doors everywhere he went. He wasn't any better at home. Sarah, a social worker who is a single mother, couldn't take her four kids anywhere for years because Oscar would always wander off. "He just has no fear," she says. "We lost him once on a Disney cruise. We spent half a day looking for him; all the staff were involved. We finally found him in our cabin. He'd been wandering for hours, then went back and ordered room service. He was in there with pizza, chicken nuggets, and ice cream."
As he got older, he wandered less, but his behavior grew more volatile—and more destructive. He still refused to do what he was told, but if you pushed him, he'd blow up. He'd break things and "tear the house apart," Sarah says.
When Oscar was 9, he injured a teacher's aide. By then he was in a special school for kids with behavioral problems, but he still stood apart for his misbehavior. The aide had approached this challenge with a drill sergeant style of discipline. When Oscar refused to do his schoolwork one day, the aide got in his face and yelled. Oscar performed his signature move, swiping his arm across his desk and knocking everything off. One of the flying school supplies hit the aide, who called the police. Oscar was handcuffed and taken to juvenile detention in the back of a police car. There, a judge lectured him about his behavior. Oscar promised never to act that way again, but the bad blood between him and the aide only made the boy wilder. Once more, he ended up leaving a school.
The aide had hit upon Oscar's strongest behavioral trigger: being yelled at. Being told no is another sure-fire way to produce a meltdown. But almost any form of frustration can do it.
"If he wants to download something on the computer and it takes too long, he starts yelling and then he starts slamming things," his mother says. "Something that most of us would just take in stride, he can't cope with. He gets into an anxiety spiral—he gets obsessed with the fact that it's not working. He's broken so many computers and iPads that I've stopped buying them."
A typical flare-up happened one Friday this spring, around midnight, when Sarah confiscated Oscar's video game controller to keep him from staying up all night. Oscar erupted, screaming at her and storming through the house, slamming doors. He was still raging when she fell asleep. The next day, when he'd calmed down, she conducted a postmortem.
"Did you break anything last night?" she asked.
"No," he said.
"Why was the hammer out this morning?"
"I don't know."
"Did you hit anything with it?"
"No....Well, I hit myself in the leg a couple times."
"Did that accomplish anything?"
"I released my frustration, and now I have a huge bruise."
"You know, sometimes you have to do what I say."
"That's no fun!"
As often as Oscar can be difficult, he can also be incredibly charming, funny, and full of wit. Although his behavior has held him back in school, his IQ is high. When he's interested in something, he studies it incessantly. He has an encyclopedic knowledge of his favorite subjects: World War II, Star Wars, the gene-editing tool CRISPR, and, of course, video games.
He's creative, too. He likes painting and drawing; once, in his school art class, he painted a strikingly good moonscape. "I mixed different paints and made a shadow around the moon. The teacher was really impressed," he explained proudly.
And despite his hostile outbursts, he cares deeply about people. He's made only one friend at school, a boy named Brian, but they are a tight pair. Brian has dyslexia but no behavioral issues, and Oscar tried to hide his extreme irascibility from him at first. But there was no concealing it for long. "Bri is just starting to notice that I have bigger issues," Oscar explained recently. "He doesn't mind, though. He said it makes me more interesting."
"Interesting" isn't necessarily the word Sarah would use. Not long after the hammer incident, Oscar blew up at his mother because she wouldn't let him buy new computer games. He smashed his iPad and ran away from home. He ended up in a nearby park, where he pretended to pass out. When the EMTs, park rangers, and police got involved, he made up a story about being seriously ill and was taken to the children's hospital—ultimately landing in the mental-health wing again.
But neither forced hospitalization nor the threat of juvenile detention has made a dent in his behavior. "You'd think these things would teach him a lesson, but that's not how he learns," Sarah says. "He doesn't think, Oh, these are the repercussions for my actions, and I won't do it again. When he came out of the hospital, it was like, life goes on....I wonder how many more times this will happen. Will it happen when he's 30?"
Clinicians who specialize in disruptive behavior disorders estimate that between 5 and 10 percent of children and adolescents meet the criteria for a diagnosis at some point. They are more often boys than girls, although some researchers believe that may be because less attention is paid to female aggression. Kids who warrant an ODD diagnosis have short tempers that erupt explosively. They're highly irritable, resistant to rules, and frequently argumentative. When provoked, they can be vengeful, spiteful, and cruel. Those with conduct disorder (CD), meanwhile, are more likely to be physically aggressive and to violate other people's rights, often by stealing from or manipulating them.
While ODD and CD are two distinct disorders, and one doesn't necessarily lead to the other, many adolescents with CD started with an ODD diagnosis. And some of those with CD will go on to be diagnosed with antisocial personality disorder as adults—a label that, to many, is synonymous with psychopathy. Adults with antisocial personality disorder have a malfunctioning moral compass: They often act criminally or unethically and show no remorse for the hurt they've caused.
Although kids with disruptive behavior disorders represent a small slice of the population, they wreak a disproportionate amount of havoc. "These kids create a lot of problems, so they tend to trigger a diagnosis faster than you would if you were a nice, sweet, anxious kid and your symptoms were internal," says Stanford psychiatrist Hans Steiner, the author of Disruptive Behavior: Development, Psychopathology, Crime, and Treatment.
But getting noticed isn't the same as getting help. And disruptive behavior disorders are among the least understood of psychiatric conditions. While drug treatments for schizophrenia, depression, bipolar disorder, and anxiety have advanced by leaps over the last 50 years, no medications at all have been developed for ODD or CD. Why don't we know more about these troubling disorders? And why aren't we better at treating them?
In part, Steiner says, it's because the field itself is one of the youngest in psychological research. Giving disruptive behaviors clinical labels—as opposed to criminal ones—is an approach pioneered in Chicago in the early 1900s to create a juvenile justice system focused on prevention and rehabilitation. It advanced in the 1920s and 1930s by a Viennese reform school director named August Aichhorn. By viewing juvenile antisocial behaviors as a marker of "developmental trajectories gone awry," Aichhorn paved the way for clinical studies—and potential interventions.
Other obstacles still stand in the path of research, however. For one thing, the defining features of disruptive behavior disorders—antisocial acts and aggression—are harder to pinpoint and study because they are also key features of normal development, especially during the toddler and teen years. When it comes to disruptive behavior, it's hard to tell where the tantrums and angst of everyday childhood end and pathology begins.
Beyond that difficulty, there is the ambiguity of the clinical labels themselves. To the frustration of many clinicians, the DSM-V criteria for ODD and CD make no distinction between reactive, explosive aggression and proactive, calculated antisocial acts; Steiner and his colleagues call these different behaviors "hot" and "cold" aggression.
That distinction is crucial, they argue, because the two forms of aggression tend to stem from different causes, activate different parts of the brain, and respond to different treatments. And while a child with ODD can erupt reactively sometimes and be purposefully cruel to others, research shows that, by and large, aggressive kids tend to align more closely with one form than the other.
Reactive aggression tends to accompany the attention problems and impulsivity that emerge early in childhood, child psychologist Christina Stadler writes in a 2010 article for Frontiers in Psychiatry. Proactive aggression, meanwhile, is linked to "psychopathy-like callous-unemotional traits," including disregard for the rights of others and an inability to feel empathy, guilt, or remorse.
Biologically, the two types are almost diametrically different. Children with a low resting heart rate and low skin conductance response—signs of autonomic underarousal—are predisposed to cold aggression, while those who show high levels of arousal are prone to hot aggression. The biological markers can be useful clinically, Steiner explains.
"When kids come into my office, one of my first steps is to check their resting heart rate. If it's below 60 or so, I know what I've probably got," he says.
Although kids with hot and cold aggression might engage in the same antisocial behaviors—say, theft—their motivations tend to be vastly different, as are the parts of the brain that trigger their behavior. A kid who steals a classmate's cell phone might do so because he feels wronged by that classmate and has been stirred to retaliate by the brain's primal threat system. Meanwhile, a kid who plans to steal a phone from a classmate who has never done anything to her is using the highest level of cerebral functioning to orchestrate the theft and avoid detection, Steiner says.
These neurobiological differences are valuable prognostic tools, according to Stadler. In her 2010 study, she reported that "low autonomic responses in 15-year-old boys are predictive of adult criminal behavior...while heightened autonomic responsiveness appears to be a protective factor" against future criminality.
Even professionals, however, struggle to predict which kids will outgrow antisocial behavior over time and which will continue on to a troubled adulthood. A 2001 study reports that roughly half of children diagnosed with ODD will still have the disorder three years later and that 25 percent are at risk for developing CD. A much smaller subset is on a path to adult criminality or antisocial personality disorder, which affects about 3 percent of men and 1 percent of women. If that's the path a kid is on, it's hard to reroute without the help of parents, teachers, and therapists who are all committed to helping him chart a new course.
Oscar was in the third grade when a psychiatrist told Sarah, "Kids like this can go down one of two paths." One path, he said, led to crime, drug use, and addiction. The second entailed regular therapy and constant vigilance to keep them off the first. Sarah was stunned. Oscar had seen a string of different therapists by then, but this one was the first to tell her explicitly what the future held for kids like her son. "It was scary and heartbreaking, and I cried and my mom cried, and we never went to see him again," Sarah recalls. "He was just being honest; it wasn't his fault. But I just wasn't at the point where I could hear that yet. He made it sound like this was going to happen. That's always stayed with me: That path is there, and Oscar could go down it."
Oscar's entire extended family has worked to steer him away from that path, and for several, it's been a full-time job. When he started at a school for kids with behavioral challenges, Oscar would get frustrated and walk out of class daily. So Sarah's mother, Shirley, a retired Methodist minister, went to school with him every day and waited in the front hall to make sure he stayed put. "Every time he'd leave the classroom, I'd put him back in," Shirley says. Of course, that's easier said than done, since reasoning with Oscar when he's worked up is usually futile. "I used techniques I wouldn't recommend as a pastor. Like guilt. And bribery."
Sarah's father, a former principal, teacher, and coach, was a harsher disciplinarian, but in recent years he's softened his approach. He realized that Oscar's challenges were not a discipline issue, and that yelling at him did nothing to correct his behavior. "I started to think: I've got to stop being a disciplinarian and start being a grandfather," he explains. He's since shifted his focus to Oscar's many good qualities and tried to be as effusive with his praise as he was with his criticism.
Oscar's love for his grandparents is obvious. He goes for walks with his grandfather; he helps his grandmother with the grocery shopping. Their love for him is equally apparent. Everyone in the family treats Oscar with compassion and respect. They make a point of never calling him a "bad" kid, even when they criticize his behavior.
"What do we tell you, Oscar?" his grandmother asked rhetorically one afternoon when Oscar was visiting. "We say, 'We always love you, but when you do the right things and do well at school, we're very proud.' "
A loving, supportive environment with firm boundaries gives kids like Oscar their best chances, experts say. But even the best possible family life can't guarantee a good outcome. Neither can drug treatments, although many kids with behavioral disorders take medication for co-occurring disorders such as ADHD and anxiety.
When Daniel F. Connor, the chief of child and adolescent psychiatry at the University of Connecticut School of Medicine, led a 2002 meta-analysis of drug trials for aggression in children and adolescents with ADHD (75 percent of whom also had a diagnosis of ODD or CD), he found that stimulants like Ritalin significantly reduced aggression. But he points out that this was true only for reactive aggression; the proactive aggression more commonly associated with psychopathy was more or less impervious to medication. "There's not much that can be done clinically for psychopathy," Connor says. "The good news is that the vast majority of kids with disruptive behavior disorders have disordered reactive aggression. They misinterpret environmental cues and react inappropriately. Psychiatry can help those kids."
Medications can target the two parts of the brain typically implicated in reactive aggression: an underactive prefrontal cortex and an overactive amygdala. Normally, the prefrontal cortex helps us regulate our impulses and inhibit aggression. "That's what we call 'holding your temper,' " Connor says. "It's a complicated bit of calculus done by the prefrontal cortex because you've decided that if you scream and throw things, it'll be bad for you in the long run. But for a lot of people with ADHD, this part of the brain isn't operating optimally. They're impulsive. They blow up without thinking, If I do this I'll get suspended from school and my parents will be mad at me, so I'd better not do it."
An overactive amygdala, meanwhile, reacts too strongly to perceived threats, making it harder for the prefrontal cortex to intervene. So clinicians focus on either increasing the prefrontal cortex function or decreasing the amygdala response—or both. One way to do that is to use cognitive-behavioral therapy (CBT) to train the brain to pause and consider alternative responses. Plus, some medications can help boost the effects of CBT, Connor says.
"Pharmacology can lengthen the fuse," he explains. "It can decrease impulsivity and allow more time for cognitive decision making. Stimulants can do it; tricyclic antidepressants can do it; Wellbutrin can do it." Patients who don't respond to these drugs sometimes improve with atypical antipsychotics such as risperidone. But medication alone can't "cure" the troubling behavior of kids with ODD and CD. That's because the behavior isn't the illness. "When a kid blows up and tears apart his classroom, that's a symptom. It's evidence of a breakdown, a nonoptimal central nervous system that's not operating the way evolution intended," Connor says. And just as we wouldn't revoke our child's iPad privileges for running a fever, we shouldn't punish kids for behavior that's a symptom of a neurological disorder, he argues.
Ross Greene, who has researched and written extensively about children with social, emotional, and behavioral challenges, believes the failure to help kids with these disorders has emerged from a basic misunderstanding of the factors behind their behavior. "What we've been thinking about these kids—that they're manipulative, attention-seeking, coercive, unmotivated, and limit-testing, and that these traits have been caused by passive, permissive, inconsistent, noncontingent parenting—is way off-base most of the time," Greene writes in Lost at School. "As a result, the interventions that flow from these ways of thinking have been way off-base as well."
Greene believes that meting out adult-imposed "consequences" to these kids is part of the problem, because it presumes that they either don't understand the difference between good and bad behavior or that they aren't motivated to choose good behavior. He argues that they do know the difference—and that they already want to behave well. What's holding them back is a kind of learning disability, he says, a delay in acquiring the skills needed to tolerate frustration and develop flexibility. "The behavior is just a signal that these kids are lacking skills," he explains. "It's the way the kid is communicating that she is stuck, or that there are expectations that she's having difficulty meeting."
Greene pioneered a form of CBT for kids with disruptive behavior disorders. Called Collaborative and Proactive Solutions (CPS), it's a treatment model that aims to help them work with their parents and teachers to solve the problems causing their behavior and to develop the skills they lack—without stiff punishments or harsh criticism. Several studies have shown that this model can reduce challenging behavior better than a traditional reward-and-punishment approach.
In a 2016 paper published in the Journal of Child and Adolescent Psychiatric Nursing, lead author Deanna P. Sams, of the University of Rochester, writes that her school's medical center adopted a version of Greene's CPS model, in which "nursing staff and clinicians began to demonstrate greater empathy, teach collaborative skills, and seek mutually beneficial solutions" with patients who had disruptive behavior disorders. Over the course of a year, this model led to a 75 percent reduction in the time that these patients needed to be isolated or restrained because of aggression.
But while some facilities are embracing Greene's approach to teaching challenging kids the skills they lack, others have doubled down on the consequences-based model, especially as school violence has become a national epidemic. One example: The zero-tolerance policies a number of schools have adopted, Greene notes, have only made the problem worse. A task force organized by the American Psychological Association concluded that these policies have, in fact, increased the levels of violence and disruptive behavior in American schools. But public schools still use them, averaging more than 100,000 expulsions and 6 million suspensions every year, along with millions of detentions.
The fact that these numbers are so high, and that a small number of challenging students account for the vast majority of expulsions, suspensions, and detentions, is proof that the traditional disciplinary model isn't working, Greene says. In a February op-ed for Time, he points to Nikolas Cruz, the 19-year-old former student accused of killing 17 people at a Parkland, Florida, high school, as an example of the failure of the existing approach to treating troubled kids.
"We had 19 years to prevent a tragedy," Greene says. "Nikolas Cruz wasn't created overnight. His trajectory was a very familiar one to those of us who work with these kinds of kids in juvenile justice centers and psychiatric facilities. We need to ask ourselves: Why do we keep losing kids like Nikolas Cruz?" The answer, he says, is an outdated treatment model. "We're losing a lot of children and a lot of teachers because we still view challenging kids the wrong way and handle them in ways that don't address their true difficulties," he explains.
Not long after Oscar's diagnosis, Sarah enrolled him—and herself—in skill-building classes to help with his behavior. One lesson she learned from those classes was to pick her battles. When Oscar isn't actively destroying property, she tries to ignore his tantrums, since the negative attention could reinforce his behavior. People who don't understand why Oscar acts the way he does sometimes ask why she's "giving him a pass," since she wouldn't let her other kids get away with similar antics.
But Kristin Carothers, a clinical psychologist at the Child Mind Institute in New York, says this approach is sound. Carothers educates the parents of kids with ADHD and related disorders about the ways they themselves inadvertently reinforce disruptive behavior. "We want parents to stop that cycle by attending only to specific acts, focusing on the positive, and ignoring minor misconduct," Carothers says.
Of course, if a child becomes aggressive, hitting people or breaking things, you can't disregard it. Carothers, who doesn't treat Oscar, recommends a time-limited, consistent response, like a time-out or the temporary loss of a prized toy. "Those aren't things you can ignore, but there's a difference between setting limits and being in a punishment mode," she says.
The focus should be on giving kids credit when they behave well, Carothers explains. The fact that this approach feels counterintuitive to many just means that the research hasn't been widely disseminated outside the clinical community. "These treatment approaches are well researched, and we know this is what works because empirical studies show that kids get better over time. It's just that these approaches may not be widespread," she says. "The research is there, but one of our challenges as psychologists is to get things out from our ivory towers and into communities."
That's why she spends as much—or more—time training parents and teachers how to respond to challenging kids as she does training the kids themselves. It can be tricky to get everyone on board. "Parents expect to bring their kid to therapy, not to bring themselves to therapy," she says. "But parents and teachers are really the first line of defense." There's only so much she can do to teach coping skills in a session, after all. To make lasting changes, kids have to practice those skills in the context of real-world triggers at school and at home, with the help of adults who can reinforce them. "Individual therapy alone hasn't been shown to be effective in the long term," Carothers says. "Contextual interventions, along with medication, have been the most helpful."
Medication has helped Oscar, but only after a lengthy trial and error that led to risperidone, the drug that best treats his irritability and poor impulse control. Sarah worries about the side effects, which for him have included weight gain and daytime sleepiness. Oscar, on the other hand, has embraced the medication.
"He takes it religiously. If he feels really agitated, he'll say, 'Let me check and make sure I took my pill,' " Sarah says. He prefers the way he feels on the medication: calmer and more in control. "He'll say, 'Do you think it's fun to be this way? It's not. I don't want to be like this.' "
Every year, his behavior has gotten a little better. He attends a school for students with autism and ADHD, where his teachers had called Sarah daily to come get him after a blowup. Now it's once every week or two. And he's been there for four years, which is the longest he's lasted at any school. After bouncing from clinician to clinician, he's been seeing the same psychiatrist for four years, and his medication hasn't changed for three. "This has been the most stable period in his life," Sarah says. "Not that it's been easy."
But next year Oscar will go to high school, and Sarah worries about what the change will mean for him. She has no idea what his future will hold; neither does he. He often talks about what jobs he might be good at. He's remarkably self-aware, and recognizes his limitations. He doesn't think college will be the right fit for him, but he believes he could learn a trade.
"School has been a really hard time for me, because it's hard to suppress things all the time. I get angry really fast," he says. "I'm going to try to make my problems not show when I'm working. I'm thinking about what would happen if I get angry or anxious." And although he talks about wanting to get married one day, he says he doesn't want to have kids because he knows his behavior could be passed down. He's afraid his kids will be like him. He's right: Both ADHD and disruptive behavior disorders tend to run in families.
Sarah understands this better than most—but it still breaks her heart to hear it. "You just want your kid to be happy and healthy and have every opportunity," she says. "When you have a kid like Oscar, you realize that's going to look different than it would for other kids." Oscar sometimes tells his mother it makes him sad that he's always going to be like this. She reminds him that he's come a long way already: "You've grown and matured, and you manage things better now."
Sarah, too, has come a long way since Oscar's early years. "I went from wanting to tell doctors, 'Solve this,' to 'OK, this is how it's always going to be, so how do we cope with it?' " she says. "It takes so long, and you try so many different things. When you get that diagnosis, you see your future ahead of you, and you think, I can't do that. But you do, because you love your kid."
There's no guarantee that Oscar will stay off the path that leads to a troubled adulthood, even if he does keep up with the recommended treatment, Connor cautions. "What we can guarantee is that if your child is in treatment, he'll do better than when he's not. But the treatment doesn't have lasting effects if you stop it—it's not an antibiotic that cures your strep throat," the psychiatrist says. A disruptive behavior disorder is "a chronic condition, like obesity or diabetes: Sometimes it's worse and sometimes it's better, and you need lifelong treatment and support."
Sarah is cautiously optimistic. Part of her still wishes there were a cure, because the alternative—a lifetime of therapy and support—takes a great deal of time, money, and effort. It would be much easier if yelling at her son actually did work. "The other way—the modeling and positive reinforcement—is so slow," she says. "It takes a long time, and you're not always sure it's sinking in. But when you see it finally begin to work, you're just so happy because it's all paid off."
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