Editor's note: This text-based course is a transcript of the webinar, Strong Willed Child Or Oppositional Defiant Disorder?, presented by Tere Bowen-Irish, OTR/L.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- After this course, participants will be able to differentiate between a strong-willed student and a student who may have the diagnosis of ODD.
- After this course, participants will be able to distinguish different risk factors that may contribute to this complex diagnosis.
- After this course, participants will be able to evaluate interventions and treatment based on signs, symptoms and possible co-morbid conditions that may be part of this disorder.
Introduction
I’m excited to be here with all of you. Today, we will explore the complexities of strong-willed children versus those diagnosed with ODD. We’ll review risk factors and, most importantly, discuss interventions that can make a difference in their lives. I’ve learned a lot while researching this topic, which has deepened my understanding of how we can help these kids beyond the surface behaviors. I hope you will walk away today with new tools and perspectives for working with these students.
The Strong-Willed Child
When I reflect on the concept of a strong-willed child, I turn to my research to better understand the nuances of their behavior. These children often exhibit behaviors that can be challenging to manage, but they are not necessarily defiant in the way that a diagnosis like oppositional defiant disorder (ODD) would suggest. Still, some similarities can emerge, so it’s important to distinguish between them.
One hallmark of a strong-willed child is angry outbursts. These children may respond selectively when given directions, often acting as if they "didn't quite hear you." This behavior isn't limited to one environment—it can be observed at home, at school, on the playground, and even within team settings. It’s widespread and not confined to a single context.
Non-compliance is another significant trait. Strong-willed children often have a pronounced sense of fairness and aren’t afraid to speak up when they feel things aren’t fair. They have no hesitation in verbalizing their frustrations, and this is often coupled with a stubborn streak. I’ve seen this inflexibility firsthand—whether refusing to change their mind or resisting help, these children tend to dig in their heels. They prefer to do things independently and question rules, boundaries, or restrictions imposed on them. This can sometimes manifest in talking back or arguing with adults.
Strong-willed children are also known for wanting their own way immediately. They often have a passionate drive for particular activities or goals, and they struggle with transitions because they don’t want to let go of what they’re focused on. Their emotions can be intense and hard to regulate, leading to impatience or impulsive actions. They may even display bossy tendencies, wanting to direct how things should be done.
As I reflect on these behaviors, it's clear that they can easily be mistaken for symptoms of conditions like ADHD, ODD, or even autism spectrum disorder (ASD). However, for the purpose of understanding the strong-willed child, I try to stay focused on traits commonly associated with ODD. It’s essential to note that while these children can be challenging, their behavior doesn’t always require a clinical label. Instead, it often speaks to their intense nature and strong sense of independence.
Strong-Willed Vs. Oppositional Defiant Disorder (ODD)
The differences between a strong-willed child and a child with oppositional defiant disorder can sometimes seem subtle, but there are clear criteria that distinguish one from the other. When we look at ODD, five specific symptoms help make this differentiation. Importantly, there is no specific test for ODD; instead, the diagnosis is based on symptomatology.
Children with ODD are often persistently angry, irritable, and easily provoked. Unlike a strong-willed child who may show frustration in certain contexts, the irritability seen in ODD is chronic and constant. This anger tends to present significant problems both at school and at home. One key aspect of ODD is that the behaviors occur across multiple environments, and when interviewing parents or teachers, it becomes clear that the challenges are present all day, every day. These behaviors go beyond normal sibling rivalry or situational defiance.
Another important factor is the duration of these behaviors. ODD symptoms typically persist for at least six months, and the frequency and intensity of the defiance are notable. No known comorbid conditions, trauma, or life events can explain the child’s behavior, which helps rule out situational causes or stressors that might contribute to temporary misbehavior in strong-willed children.
Interestingly, the article I reviewed delved into the physiological aspects of ODD, suggesting that hyperactivity in the hypothalamus or adrenal glands could play a role. When under stress, the child’s brain releases adrenaline and cortisol, disrupting normal functioning. Cortisol, in particular, affects the brain’s ability to regulate behavior. As Dr. Burns succinctly said, "Cortisol kind of shorts out the rest of the brain."
This means that cortisol can interfere with the frontal lobes, the part of the brain responsible for rational thinking and self-regulation. Under stress, the child with ODD may enter a heightened "fight or flight" mode, where impulse control diminishes and irritability escalates. This physiological reaction explains why a child with ODD may lash out with statements like, "I don't like you" or "I hate you"—their brain is quite literally flooded with stress chemicals, impairing their ability to think rationally or control their emotions.
So, while a strong-willed child may push boundaries, challenge authority, or even act out in moments of frustration, these behaviors are generally more situational and can be managed with proper support and structure. In contrast, a child with ODD faces a more pervasive, physiological challenge that affects their ability to regulate emotions and behavior consistently, and this presents in a much more enduring and disruptive way.
Causes of ODD
According to the Mayo Clinic, there is no definitive cause for oppositional defiant disorder (ODD), but there are several potential contributing factors, and the risk factors associated with the disorder are quite extensive.
Environmental factors play a significant role in the development of ODD. For instance, trauma, harsh punishment, neglect, lack of consistent care, and abuse are all possible influences. These factors point to the child's environment as a key area to explore when considering what may be contributing to the disorder. However, as practitioners, we often don’t have full access to what’s happening at home or in the child's private life. This limitation can make it difficult to fully understand the root causes of a child's behavior, as we aren’t always privy to these intimate details.
Another possible contributor is the child’s genetic predisposition. We must consider the student’s temperament—how they respond in various situations and what personality traits stand out. Some children may have a natural disposition that makes them more susceptible to developing ODD. Additionally, we must take into account whether there is a history of other diagnoses, such as ADHD, autism spectrum disorder, or other conditions, as these may also influence the child’s behavior and complicate the clinical picture.
Understanding these factors, even in part, allows us to approach the situation with empathy and a broader perspective, recognizing that ODD is not simply a result of a child’s willfulness or defiance but is often rooted in a complex interplay of environmental, genetic, and temperamental factors.
Characteristics and Risk Factors of ODD
When considering the characteristics of oppositional defiant disorder, it’s important to recognize that the severity of these traits can vary along a continuum—mild, moderate, or severe. Understanding this can help tailor interventions and approaches to the child’s needs.
We’ve already touched on irritability, often combined with defiance. Imagine a scenario where you're working with a child, and you’ve come prepared with an activity—perhaps a ball game or something new for that session. You present it, only to be met with crossed arms and a firm refusal: "I don't want to do that. I want to do what we did last week." This resistance is typical, especially in cases where the child feels that any deviation from their preference is an imposition.
One key indicator of severity is how long the behavior persists. For example, vindictiveness lasting for six months or more often leaves caregivers and educators at a loss, wondering how to break the cycle. This kind of stubbornness can be exhausting for everyone involved, as it feels like the behavior is never-ending.
There’s also the issue of heightened sensitivity, particularly to sensory stimuli. Although there’s no solid clinical documentation linking auditory sensitivity to ODD, I’ve observed that many children with the disorder struggle with noisy or chaotic environments, such as classrooms. They may become easily annoyed by their peers or overwhelmed by background noise, responding with frustration or aggression. From a therapeutic perspective, it’s crucial to be aware of this potential sensitivity when working with these children. When they feel overstimulated or agitated, they may even lash out verbally, saying hurtful or mean things to teachers or peers.
Children with ODD also tend to hold grudges, sometimes seeking revenge for perceived wrongs. This can manifest as scapegoating or deliberately annoying others to provoke a reaction. They frequently project blame onto others, deflecting responsibility for their actions, and they often engage in arguments over even the smallest issues.
When considering a diagnosis of ODD, it’s essential to evaluate the child’s environment, particularly the school setting. Are there inconsistencies in discipline or feedback that might reinforce the child’s negative behavior? Is the classroom structured with routines and scaffolding that help the child feel secure and grounded? Too many choices or too much unpredictability can overwhelm a child with ODD, exacerbating their difficulties with emotional regulation.
Another question we need to explore is whether the child has broader challenges with dysregulation. Can they articulate their emotions, or do they struggle to express themselves beyond "I don’t feel good" or "I feel bad"? Emotional regulation is often a significant hurdle for these children, and their frustration can build up quickly if they lack the tools to manage it effectively.
Family dynamics also play a critical role. Mental illness in the family, ongoing divorces, or changes in home routines can all contribute to the child’s behavior. I recall a child I worked with a few years ago whose parents were going through a divorce. He had a twin, and there was a discussion about separating the twins—one living with each parent. This decision completely dysregulated the child, and he became highly resistant to any intervention. His refusal to engage became a roadblock for the school and his family. Eventually, after conversations with both parents, they decided to keep the twins together, rotating their time between each parent’s house. This change in custody arrangement brought some much-needed stability, and we finally made progress in helping him manage his emotions.
In cases like this, it’s evident that the combination of environmental, emotional, and familial factors can all contribute to the severity of ODD symptoms. Recognizing where a child falls on this continuum—mild, moderate, or severe—can guide our strategies to help them navigate their emotions and behaviors more effectively.
American Academy of
Child and Adolescent Psychiatry
I recently explored some statistics from the American Academy of Child and Adolescent Psychiatry that I found particularly insightful. According to their data, between 1% and 16% of students are diagnosed with oppositional defiant disorder (ODD), making it a relatively small portion of the population. It’s important to distinguish ODD from disruptive mood dysregulation disorder (DMDD), which tends to manifest between six and ten years old and can last up to a year. The two disorders are often confused but have distinct characteristics and timelines.
I’m also currently part of a study group board through the Children’s Mental Health Research Center in Hawaii. I attend monthly meetings where we delve into current research and emerging topics in child mental health. One of the more recent discussions centers around potentially reinstating the bipolar diagnosis for children, which had been removed in favor of disruptive mood disorder. Researchers are considering returning it, as they find links to mitochondrial challenges, specifically regarding energy levels and temperature regulation. It’s a fascinating area of research, and for those interested in learning more, I encourage digging deeper into these topics.
What I want to emphasize, though, is that diagnosing ODD, or any related disorder, is far from straightforward. It’s a complex diagnosis with a wide range of contributing factors. However, there is some good news—about 67% of children with ODD see their symptoms resolve within three years. Unfortunately, for about 30%, the disorder can progress into conduct disorder, especially for those diagnosed at a very young age. This highlights the need for early intervention and prevention, helping these children develop the coping skills to manage their behavior and emotions before they escalate.
Focusing on preventive strategies, supporting parents, and providing more targeted interventions in schools and communities can make a significant difference for these kids. It’s about recognizing the complexity of their challenges and offering consistent, compassionate care
More Statistics
Oppositional defiant disorder is more common than some may realize, with roughly 3 million cases diagnosed each year. We’ve already discussed the genetic predispositions, including a child’s natural temperament, and how these factors can set the stage for the development of ODD. In addition to genetics, inconsistent care and harsh punishment can further exacerbate the situation, creating an environment where the child’s defiant and oppositional behaviors continue unchecked.
When left untreated, ODD can lead to more serious issues down the road. Children may turn to substance abuse as a way to self-medicate, attempting to cope with the emotional turmoil and lack of impulse control they experience. In more extreme cases, this can also lead to self-harm or even suicidal tendencies. The inability to regulate impulses and emotions becomes pervasive, affecting the home environment and their experiences in the community and at school.
The developmental demands placed on children as they grow further highlight the challenges of ODD. As they advance through school and are asked to navigate more complex social, academic, and emotional landscapes, oppositional behaviors often become more pronounced. Their tendency to say “no” or resist guidance can hinder their ability to form meaningful connections. Without proper support, these children risk losing friends and social connections, which are essential for their overall development and well-being.
The road for a child with ODD is undeniably difficult, but early intervention and targeted strategies can make a significant difference. As professionals, we must ask ourselves, “Can we help this child? Can we intervene effectively?” The answer is critical because, with the right support, we can help them manage their impulses, develop social skills, and navigate the complex demands of life without the severe long-term consequences they might otherwise face. It's a challenging path that can be navigated with care and the proper interventions.
Development/Parenting Styles
When considering development, it's important to recognize that defiance is a natural part of a child's growth. The defiant behaviors we often see typically emerge between 18 and 24 months and tend to peak around age three. At this stage, defiance isn’t pathological; it’s a normal expression of a child testing boundaries and asserting independence. However, it becomes pathological when the defiance continues beyond these typical developmental stages and becomes more frequent, severe, and pervasive.
What differentiates typical defiance from oppositional defiant disorder is the continuity and intensity of the behavior. When these defiant behaviors persist in an overwhelming manner, no longer tied to developmental milestones, they start to signal a potential diagnosis of ODD. This diagnosis is based on frequent, persistent argumentative, and defiant behaviors that go beyond what is expected for the child’s age or developmental stage.
It's crucial to recognize the tipping point where defiance stops being a phase and starts becoming a more serious behavioral issue. When a child’s defiance is no longer part of normal growth and development and instead becomes a pattern that disrupts their daily life and relationships, we need to start considering the possibility of ODD. Understanding this distinction helps identify when early intervention is needed to prevent these behaviors from becoming more deeply ingrained and harmful to the child’s social and emotional development.
ODD: Current Insights
When we consider the progression of disruptive behavior disorders like oppositional defiant disorder (ODD) and conduct disorder, it’s essential to understand their distinctions and how they impact both individuals and society. Conduct disorder, in particular, is characterized by behaviors that impinge on the rights of others and violate age-appropriate social norms, setting it apart from ODD in terms of severity. While both are disruptive behavior disorders, the concept of these disorders was first introduced over 50 years ago, and our understanding of them has evolved significantly since then.
Recent discussions on ODD highlight the significant impairments caused by these behaviors. The disruptive nature of these disorders not only affects the individuals but also increases societal costs. While mild to moderate forms of ODD often improve with age, the severe cases can develop into conduct disorder, where the behaviors become more extreme and socially harmful.
When it comes to cognitive ability, the prognosis for children with ODD or conduct disorder can be quite poor, particularly when there are intellectual challenges or a lack of proper supervision in their lives. Initially, these disorders were seen primarily as behavior problems, and for many, they are still not classified as psychiatric disorders. However, recent findings are beginning to show biological correlates, prompting a shift in how these conditions are viewed.
Research into conduct disorder, disruptive behavior disorder, and ADHD has uncovered new biological insights, suggesting that these conditions may not simply be behavioral but also have underlying physiological components. This evolving understanding has led to discussions about the potential use of medication in some cases, with considerations for antipsychotic or mood stabilizers being explored as part of treatment plans.
Despite these advancements, the "jury is still out" on the definitive nature of these disorders. The ongoing research into their biological basis is reshaping how we approach their treatment, but the debate continues as to whether they should be classified as true psychiatric conditions. This shift in perspective and the potential for medical intervention marks a significant change in how we address these complex and challenging behaviors.
The Myths of ODD: Dr. Fink
When we consider the broader scope of disruptive behavior disorders like conduct disorder and oppositional defiant disorder, it's important to note their shared traits, such as the impingement on others' rights and the violation of age-appropriate social norms. These disorders have been studied for over 50 years, and although our understanding of them has evolved, there are still challenges in how we view and treat them. The same author who highlighted these traits also talked about the significant impairments these behaviors cause—not just for the individual but also for society, leading to increased costs related to education, healthcare, and even legal systems.
While mild to moderate forms of ODD may improve with age, more severe cases can progress into conduct disorder. Children with severe ODD often have a poor prognosis, particularly when cognitive ability and proper supervision are lacking. Initially, ODD was seen primarily as a behavioral issue rather than a psychiatric one. However, recent biological research suggests that there may be underlying physiological components, particularly in studies focusing on conduct disorder, disruptive behavior disorder, and ADHD. These findings have led to discussions about the possible use of medications, such as antipsychotics or mood stabilizers, to manage symptoms in certain cases.
As I explored further, I came across the concept of the "myth" of ODD. We've all heard from colleagues that certain children are "trouble," often describing them as kids who never cooperate and always say "no." The diagnosis of ODD has been around since 1980, and in cases where defiance persists beyond typical developmental stages, one author referred to it as "reflex refusal." This term is apt when you think of a two-year-old—at that stage, saying "no" is often an automatic response, even when they might want to do the activity. Similarly, children with ODD continue to have a reflexive "no," but instead of being willfully defiant, their responses are more like symptoms of underlying anxiety. Their refusal is not manipulative but rather a self-protective mechanism rooted in anxiety and often triggered by a fight-or-flight response.
This led me to think more about the role of ableism in how we perceive children with ODD. Ableism is a cultural phenomenon in which ability is presumed, and disability is ignored, judged, or dismissed. In the case of ODD, ableism manifests in the assumption that all children are equally capable of meeting adult demands. When they don’t, it’s often assumed that they simply don't want to or that they’re being difficult. But as the author points out, these children aren’t plotting to be argumentative or defiant—they’re reacting to situations without full cognitive awareness. Their behavior is subcortical, driven by deep-seated anxieties they may not understand.
I’ve witnessed this "reflex refusal" in students, and as therapists, we must continually ask ourselves why the behavior is happening. Taking ODD at face value—viewing it as simply oppositional behavior—doesn’t help anyone. We must treat it as a symptom, much like a fever, and dig deeper to understand what’s causing it. Instead of just managing the opposition, we should uncover the root causes.
In my experience, casual conversation is the best way to begin understanding these underlying causes. While playing or working with a child, I’ll ask open-ended questions: “How was your weekend?” or “Did you sleep well last night?” I often hear small details about their home life or emotions through these questions—“I couldn’t sleep because my parents were fighting” or “I’m mad because my brother took my stuff.” These little revelations help create a fuller picture of what the child is experiencing, and sharing this information with the psychologist, social worker, or educational team can be instrumental in crafting a more informed and supportive approach.
We also need to be aware of potential comorbid conditions, such as ADHD, selective mutism, and others, that might contribute to the child’s anxiety and reflexive behaviors. These conditions can push a child into a fight-or-flight state, where they feel the need to escape or defend themselves.
PANDAS
I recently had an experience that I think is important to share, especially regarding how crucial accurate diagnosis can be in addressing childhood behavioral challenges. A colleague, who is not in our field but is a mutual acquaintance, contacted me regarding her friend’s three-year-old daughter exhibiting some concerning behaviors. The mother had noticed a sudden change in her daughter's behavior, and they were looking for some insight.
Before I dive into the details, let me tell you the conclusion: the little girl was eventually diagnosed with PANDAS or PANS syndrome, which stands for Pediatric Acute-onset Neuropsychiatric Syndrome. It’s a condition that can come on abruptly and cause a range of neuropsychiatric symptoms, often following infections like strep throat.
In this case, the onset occurred in October, and the girl started acting out clearly outside of normal developmental behavior. She began regressing—wetting her pants, which had previously not been an issue. Her anxiety skyrocketed, especially when her mother left for work. The child would cling to the babysitter, clawing at her in desperation as her mother walked out the door. In addition to toileting regression, she stopped dressing herself, became extremely picky about food, and displayed severe sensory issues. She invaded others' personal space and frequently threw herself on the floor in what can only be described as sensory-seeking, crashing, and burning activities. There were also notable sleep disturbances and significant tantrums.
Her mother had already tried occupational therapy through a hospital but hadn’t found it helpful. I agreed to work with her, but after three or four sessions, it became clear that this was beyond my scope. This little girl’s tantrums were far beyond what you’d typically see—she would pound her fists on the floor, bite her own arm, and completely lose control when asked to do something as simple as picking up toys before transitioning to another activity.
Another red flag arose as her preference for her mother became more intense. She refused to allow her father to bathe her or put her to bed, insisting on her mother’s presence for these activities. The parents decided to take her to Dartmouth Hitchcock in New Hampshire, where she was ultimately diagnosed with PANS. The treatment regime involved anti-inflammatory medications like Motrin and antibiotics, as her doctors believed the condition had been triggered by untreated strep throat, which can lead to conditions like rheumatic fever.
This diagnosis reminded me of another case I had encountered earlier in my career, where a child’s sudden behavioral changes were linked to an undiagnosed infection. Reflecting on the case, I realized how critical it is to look beyond surface behaviors. If I had followed the pediatrician’s initial suggestion to label her behavior as oppositional defiant disorder and pursue medication for that, we would have missed the underlying medical issue entirely.
This case underscores the importance of taking the time to thoroughly explore all potential causes of a child’s behavior. It also highlights the need for collaboration across medical, psychological, and therapeutic disciplines. The girl is now receiving play therapy, and her parents are participating in family therapy to learn how to cope with and support their daughter through this difficult time. It’s a fascinating case, and I felt it was important to share the experience with you all, as it reinforces the need to carefully assess and approach each child holistically, ensuring that the root cause of their behavior is properly identified.
Diagnosis
Clinicians must use validated assessment tools to ensure an accurate diagnosis of oppositional defiant disorder. While we may not always be directly involved in the diagnostic process, it is helpful to be familiar with specialists' tools. This knowledge can aid in understanding the results or help guide conversations when a diagnosis is still unclear.
Here are some of the primary assessment tools used to help clinicians identify ODD:
- Child Behavior Checklist (CBCL): A widely used tool that helps evaluate a wide range of behavioral and emotional problems in children.
- Conners Child Behavior Checklist: Similar to the CBCL, this assessment is particularly useful for identifying behavioral problems related to attention and oppositionality.
- Behavior Assessment System for Children (BASC-2): This tool assesses various aspects of behavior and emotions, helping to identify children's strengths and problem areas.
- Strengths and Difficulties Questionnaire (SDQ): A brief behavioral screening tool that evaluates emotional symptoms, conduct problems, hyperactivity, peer relationship problems, and prosocial behavior.
- Child and Adolescent Psychiatric Assessment (CAPA): A comprehensive interview-based tool designed to assess a range of psychiatric disorders in children and adolescents, including ODD.
- Development and Well-Being Assessment (DAWBA): This tool combines structured questions with clinical judgment to assess mental health problems in children and adolescents.
- Disruptive Behavior Diagnostic Observation Schedule: Used to directly observe and assess disruptive behaviors in children, helping clinicians identify patterns consistent with ODD.
These tools provide clinicians with a structured approach to assessing and diagnosing ODD, allowing them to differentiate between oppositional defiance and other potential conditions.
Treatment
When treating ODD, it's essential to acknowledge that this condition often requires a 24/7 approach. Since these behaviors don't just happen in isolation, involving the child's family is critical to ensure consistency across all environments. Parents need to be on the same page regarding self-regulation strategies, as this will help create a cohesive support system for the child.
As therapists, our role often involves helping the child develop self-regulation techniques—whether it's through breathing exercises, structured activities, or fostering co-connection and problem-solving. It's also important to observe how the child socializes during unstructured times throughout the day, such as recess, lunch, or other activities where their behavior might differ from structured settings. Teachers' observations can be invaluable in providing a broader picture, as the child may behave very differently in a classroom of 20-25 students compared to the brief, one-on-one therapy sessions we conduct.
When involved in direct intervention, assessing the routines and rituals in the child's daily life is key. Dr. Russell Barkley's work on ADHD highlights how children come to school with a finite amount of cognitive "fuel." Without predictable routines, that cognitive "gas tank" quickly depletes, leading to a higher likelihood of fight, flight, or freeze responses. As therapists, we might ask the child, teacher, or parents about the predictability of their routines. Are there regular rituals they can rely on, reducing the need for conscious thought and decision-making, which can drain their mental resources?
Direct intervention in the classroom can also be a valuable tool. Being present during group projects or discussions allows us to offer "point-of-performance coaching," which provides real-time scaffolding. For example, if a child with ODD is hesitant to participate in a class activity, gently prompting them—"You know the answer to this, go ahead, raise your hand"—can empower them and reduce their feelings of self-doubt or rejection.
One of the most effective techniques for children with ODD is establishing a trusting, compassionate relationship—what I call co-connection. Rapport is critical. Early in my career, I focused heavily on treatment plans and goals, but I’ve come to realize that the therapeutic relationship is paramount. Building trust and rapport may take longer with these children, but it significantly increases the chances of success in the long run.
For example, I once worked with a group of fourth and fifth graders, one of whom had ADHD and ODD. Whenever we started an activity, he would immediately find fault. In one instance, we were planning an obstacle course for younger children, and he became upset when another child wanted to teach dribbling, which he also wanted to do. Instead of dismissing his frustration, I facilitated a problem-solving discussion between the two students, finding a way for them to both contribute by teaching different aspects of basketball. This collaborative problem-solving fosters social skills and co-connection with peers, reinforcing positive interactions.
Another important aspect of treatment is helping children recognize and manage their emotional responses. Self-awareness techniques, such as mindfulness, can help the child identify where they feel tension or frustration in their body. For example, I might say, "I notice your fists are clenched when you’re upset. Do you feel the tension in your chest or elsewhere?" This nonjudgmental approach encourages the child to reflect on their emotions rather than acting impulsively.
We must also provide consultation and collaborate with the broader team—teachers, parents, and other professionals—to ensure the child’s environment supports their success. This may involve adjustments to seating arrangements, implementing sensory breaks, or using tools like visual schedules and timers to help the child anticipate transitions and reduce anxiety. For example, a simple heads-up from the teacher—"Don’t forget we have our timed tests tomorrow"—can prevent unnecessary stress.
Finally, it’s important to look at unstructured times, such as lunch and recess, where social challenges often arise. In one school, I initiated a game group during lunch for children who tended to cause trouble after finishing their food. This helped create a more structured, positive environment and diffused potential conflicts.
Overall, treating ODD requires a holistic approach that considers the child’s behavior and the environment, routines, and relationships they navigate each day. Through consistent, supportive strategies, we can help these children build the skills to manage their emotions, foster positive social connections, and succeed in school and beyond.
Faulty Neuroception/Beyond Behaviors
I've recently come across a remarkable author, Mona Delahooke, whose work has been invaluable in helping me understand Polyvagal Theory as it applies to school-age children, particularly those with oppositional defiant disorder and other behavioral challenges. Her approach is grounded in the Polyvagal Theory by Stephen Porges, which emphasizes the importance of the nervous system in understanding behavior. Delahooke uses the term "faulty neuroception" to describe what happens in children when their nervous system misreads environmental cues, causing them to fight, flight, or freeze mode. Her book, Beyond Behaviors, and an accompanying flip chart have been a powerful tool for therapists and teachers. It helps in better understanding causation and developing strategies to address the root of these behaviors.
Delahooke calls on us to redefine our approach to behavioral challenges, echoing the research that encourages a deeper dive into the causes behind a child's actions. As Dr. Fink mentioned in earlier studies, it's crucial to ask: Is the behavior stemming from issues at home? Is it something happening at school? Or are we witnessing a neurobiological response rather than a deliberate misbehavior?
One of the most important points Delahooke makes is that if a child is in a state of fight, flight, or freeze, expecting them to respond to a reward system is unrealistic. Many behavior programs rely on a reward system—tokens, prizes, a special activity, or pizza on Fridays. However, if a child is in a state of physiological dysregulation, these rewards are meaningless to them. They are not operating from a place where cognitive control is possible, so no matter how desirable the reward is, it won’t influence their behavior. Instead, their misbehavior reflects their inability to regulate their physiological state.
Delahooke also stresses that self-regulation is developmental. We might see glimpses of self-regulation, but expecting a child to maintain constant behavioral control is unrealistic. I often make this point when I speak to teachers, asking them, "Are you going to be able to pay attention to me 100% of the time for the next hour, two hours, or six hours?" Of course, the answer is no—it’s humanly impossible. Imagine a child constantly being called out for misbehavior, perhaps because they’re irritable, angry, or distracted. Expecting them to "keep it together" all the time is unfair.
What resonated with me from Delahooke’s work is her concept of co-regulation and co-connection. If our nervous system, as therapists or educators, is calm and regulated, we can also help the student regulate. This relationship is critical. A calm, predictable presence is far more effective than trying to control the child’s behavior through shaming, physical isolation, punishment, blaming, yelling, or other harsh techniques. When we use a stern voice or glare at a child, we might think we're disciplining them, but we could be pushing them further into dysregulation, escalating the behavior we're trying to stop.
Delahooke emphasizes that a calm, open, and regulated nervous system—our own—can serve as a powerful tool to help a child adapt and self-regulate. The goal isn’t to condone or accept inappropriate behavior but to approach the child curiously, asking, “What’s going on? Tell me more about what you're feeling right now.” This approach fosters connection rather than creating more distance, which is critical for helping children move toward more positive behavior.
By focusing on co-regulation, we can create a safe and supportive environment for these students. It shifts the focus from controlling the behavior to understanding the child's physiological and emotional state, allowing us to help them feel safe and behave better. This approach has the potential to make a significant difference, not just for students with ODD, but for a variety of behavioral challenges.
Co-Regulation Ideas
Co-regulation activities can be incredibly fun and effective in building rapport with children while helping them regulate their nervous systems in a safe and supportive way. I’ve found that these activities create a sense of connection and encourage a natural flow of engagement and playfulness. Here are some of my favorite co-regulation techniques that I use with kids, which also help develop trust and allow them to feel more in control of their emotions and bodies:
Squeeze, Please: If touch is appropriate for the child, I use deep pressure by gently squeezing their arms. We sit across from each other, and I start at their hands, gradually moving up to the elbows, triceps, and shoulders. Sometimes, I add joint compressions in their hands to provide more sensory input, and we might talk or sing a song, depending on their age.
Funny Face Mirror: This is always a big hit! I make a silly face, and the child copies it. Then they make a face, and I copy it. We can develop a few different faces and see if we can match each other. It’s a lighthearted way to share an interaction that promotes co-regulation through imitation.
Gentle Tug of War: We play a gentle tug of war using a large strap or bungee cord. This provides great sensory input through pulling and resistance, and it's a great way to engage the child's energy while regulating their nervous system through cooperative play.
Rock, Paper, Scissors Playoffs: We take a classic game like Rock, Paper, Scissors and turn it into a mini-tournament, doing the best eight out of ten rounds. It's a simple but engaging way to connect and practice taking turns.
Theraband Push-Pull: Sitting across from each other, we each loop a Theraband around our waists and hold the ends. We push up, pull down, widen our arms, and bring them close, creating coordinated movement. It’s fun to synchronize our actions and engage in mindful physical activity.
Balloon Balance: We both hold the sides of a balloon and move it together without dropping it. We go up, down, left, right, and see how coordinated we can be. This is a great co-regulation activity that encourages both focus and coordination.
Mirror Movements: I lead a movement, and the child copies it. Then, the roles reverse. We experiment with different movements and patterns, which helps the child feel connected and attuned to me.
Pom Pom Soccer: I make a small goal with my hands, and the child tries to flick a pom pom into it. This can quickly become a playful competition, perfect for developing coordination while sharing laughter.
Blowing Bubbles: We blow bubbles and try to keep them in the air by gently blowing them away, or we pop them with our fingers, fists, or even claps. It’s an easy and joyful activity with lots of laughter and sensory interaction.
Row, Row, Row Your Boat: Sitting in boat pose from yoga, we hold hands and rock back and forth while singing Row, Row, Row Your Boat. This activity blends physical movement with rhythm and song, enhancing co-regulation through soothing repetition and connection.
Tapping Techniques: Together, we tap areas of our bodies to release tension—starting at the forehead, down by the eyebrows, temples, cheeks, under the nose, on the chin, along the jaw, and down the chest. This works especially well with older children, allowing them to become more aware of their bodies and release stress in a guided way.
Balloon Batting: We hit a balloon back and forth, but instead of just using our palms, we switch it up with elbows, fists, or even our heads! The goal is to see how long we can keep the balloon in the air, naturally leading to giggles and collaboration.
These activities may seem simple, but labeling them co-regulation exercises helps bring intentionality to the interaction. They allow the child’s nervous system to attune to mine, fostering a sense of safety and connection. As we engage in these fun and light-hearted games, I often notice a natural flow of silliness, laughter, and shared enjoyment, which creates the perfect environment for helping the child regulate themselves and build self-awareness.
Dr. Ross Greene: Lost at School
In my practice, Dr. Ross Green's approach to handling complex behavioral challenges is invaluable, particularly his emphasis on non-confrontational co-regulation. After attending three or four training courses over the years, I regularly incorporate his techniques into my work with children. What resonates with me most is Green’s perspective that behavioral challenges stem from delays in emotional and thinking skills rather than academic deficiencies. He reframes these difficulties as a type of learning disability where children lack critical skills in areas like reading nonverbal cues, managing rejection, and understanding the emotional impact of their actions on others.
For example, Green describes how children with ADHD often struggle with a lack of emotional and social problem-solving skills, leading to an increased risk of oppositional defiant disorder. He explains how these kids might not realize how their actions affect others or be able to articulate their frustrations when they feel overwhelmed. In my own experience, this explanation is particularly helpful when dealing with a student whose behavioral outbursts seem sudden or inexplicable. These children aren't acting out of malice; they are reacting to a developmental delay in managing complex emotional situations.
I’ve seen firsthand how this plays out when parents, perhaps hesitant to medicate their child for ADHD, overlook the growing risk of ODD. As the child's behavior escalates—more temper outbursts, increased arguing, and defiance—it becomes clear that the problem goes beyond being "just a busy kid." Green’s data also highlights the connections between ODD, conduct disorder, and mood disorders like bipolar disorder. This makes understanding the root causes of behavior all the more critical, as behavior is often the outward expression of underlying diagnoses.
In practice, I use many of Green’s specific techniques for interaction, which aim to better understand the etiology of these behaviors. Rather than being accusatory or confrontational, I might say, “I’m confused—what’s up? Can you tell me more about it?” This simple, reflective approach is powerful in de-escalating tense situations and encouraging children to express their emotions in a safer, more controlled way. It’s about being curious rather than judgmental, shifting the focus from the immediate behavior to the underlying cause.
One example comes to mind: A student returned from lunch visibly upset, throwing their books on the floor and shouting, “I’m not doing this anymore!” In the past, I might have been tempted to address the outburst directly, focusing on the disruptive behavior. But using Green’s approach, I guided the student away from the scene, calmly saying, “You must be pretty upset—what’s going on?” The student initially resisted, telling me to go away. Instead of pushing, I responded with, “I care. Where were you before this? When did you start feeling so upset?” This patient and non-threatening approach often helps students feel safe enough to eventually open up.
If they’re not ready to talk, offering them time and space is another key aspect of Green’s method. I might suggest, “Why don’t you take some time in the beanbag, or let’s take a walk? We don’t have to talk right now, but when you’re ready, I’m here.” This non-pressuring approach allows the child to regain emotional control without feeling judged or cornered, creating a space where meaningful reflection and communication can happen later.
Overall, Dr. Green’s work has helped me understand that the behavioral challenges I encounter are often the result of underlying developmental delays in emotional and thinking skills. His methods have helped me build stronger connections with my clients, allowing me to better support their growth in a respectful, non-confrontational, and empowering way.
Conclusion: A Compassionate Perspective
In closing, I hope I’ve provided insight into the complexity of ODD. These children are not simply defiant for the sake of being difficult; they are often struggling with deeper emotional and neurological issues that manifest in opposition and defiance. Imagine waking up daily feeling irritable, angry, and out of control. These kids often don’t know why they feel this way, and without intervention, their behaviors can spiral, leading to more severe issues down the road.
We have a unique opportunity to make a difference. By building rapport, providing structure, and using co-regulation techniques, we can help these children gain control over their emotions and behaviors, offering them a path toward a more positive future.
Internet Resources
- Oppositional Defiant Disorder (ODD) Fact Sheet (ecac-parentcenter.org)
- Oppositional defiant disorder: Symptoms, causes, diagnosis and treatments (msn.com)
- https://www.learnfasthq.com/blog/5-signs-of-oppositional-defiant-disorder-4-ways-to-help-an-odd-child
- https://www.parents.com/strong-willed-child-signs-benefits-and-tips-8421719
Wrap Up/Mindfulness Practice
Let’s end with a brief mindfulness practice. Close your eyes or soften your gaze and think of a child you work with. Picture their face, and if they’re not smiling, imagine them smiling now. Silently say these words: “May you be happy, healthy, and at ease. And may I help you achieve these things in our time together.”
Thank you for your attention today, and I hope you leave with new strategies to help the children in your care.
Exam Poll
1)The criteria that differentiate ODD from a willful child or one that is misbehaving include ALL EXCEPT:
They are not easily soothed so C is the correct answer.
2)What is a TRUE statement about ODD?
All of the statements are true, so D is the correct answer.
3)Which is NOT a characteristic of ODD?
They are often not polite and respectful to authority figures so C is the correct answer.
4)What is a risk factor of ODD?
The correct answer is D, as these arse all risk factors.
5)All of the following are interventions for a child with ODD EXCEPT:
B is the correct answer.
Questions and Answers
Can a child be diagnosed with ODD if they have already been diagnosed with something like ADHD or ASD and meet the other symptoms of ODD?
Yes, they can. There can be comorbidity between ADHD and ODD.
Do girls present ODD the same way as boys?
I don’t know that answer off the top of my head. I do know there are definite differences in ADHD presentations between boys and girls, but by adulthood, there are equal diagnoses between the sexes. I’m not sure if that applies to ODD.
Should ODD screening be prioritized in early intervention or once a child enters school?
I wouldn’t necessarily call it ODD screening, but we should prioritize self-regulation skills early on. Assessing how children handle frustration, compromise, and negotiation is important. Looking at self-regulation in general can help identify a range of possible diagnoses.
How would you educate ABA or behavior-based professionals about ODD and positive interventions?
That’s a challenging task. I have seen some resistance to alternative strategies from ABA professionals in early intervention (EI) and school settings. They often rely on token systems and structured approaches like "first and then." It’s an ongoing battle. A top-down approach is needed, where the team looks at different theories and works together. ABA’s rigidity can cause inconsistencies in treatment across different environments.
Do you ever pause or halt OT sessions due to a child’s behavior? What do you do when a child refuses to participate or is opposed to everything?
Yes, I’ve encountered those situations. I shift my approach when a child is inflexible or refuses to engage. I start by educating them about our session. For example, I’ll outline a few games we can play—like "Perfection," "Don’t Break the Ice," or "Banana Grams." I’ll explain that we’ll start with mindfulness or breathing exercises before choosing a game. Then, the last five minutes can be their choice. I try to create a cooperative session where they feel some control. If this approach doesn't work, I'm happy to provide more ideas via email.
Is there any treatment for adults with ODD, or are they just considered to have conduct disorder at that point?
With adults, treatment often shifts toward the use of medication, possibly including cognitive behavioral therapy. I didn’t focus much on adult treatment in my research, but the use of medication is becoming more common.
Is there a particular age range during which a child can be diagnosed with ODD?
ODD typically starts to show up after the developmental stages of two to three years old, when behaviors like saying "no" become more pervasive. It can be diagnosed at any age but usually becomes evident after this period.
If a child under three exhibits ODD-like tendencies, how can you steer them away from these behaviors before they become permanent?
Some of it is developmental. When a typical three-year-old is angry or upset, you can acknowledge their feelings while setting clear boundaries. Distraction works well with young children. But yes, you don’t want these behaviors to become permanent. Teaching social-emotional skills early on can be very helpful. Occupational therapy practitioners and speech and language pathologists can play a key role in helping children understand emotions and appropriate responses.
How should you respond when students make impulsive, rude, or off-putting comments? Should we try to be compassionately curious in these moments?
Exactly. You’ve got it. Try a more compassionate approach instead of responding harshly or calling them out for being rude, which can put them into fight-or-flight mode. For example, you might say, "Hey, let’s step out into the hall for a second. What’s going on?" This approach helps de-escalate the situation and shows that you’re trying to understand their behavior rather than just punishing them.
References
Aggarwal, A., & Marwaha, R. (2022). Oppositional defiant disorder. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Updated 2022 Sep 19. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK557443/
Arias, V. B., Aguayo, V., & Navas, P. (2021). Validity of DSM-5 oppositional defiant disorder symptoms in children with intellectual disability. International Journal of Environmental Research and Public Health, 18(4), 1977. https://doi.org/10.3390/ijerph18041977
Burke, J. D., Evans, S. C., & Carlson, G. A. (2022). Debate: Oppositional defiant disorder is a real disorder. Child and Adolescent Mental Health, 27, 297-299. https://doi.org/10.7759/cureus.9521
Del Valle, P., Kelley, S. L., & Seoanes, J. E. (2001). The "oppositional defiant" and "conduct disorder" child: A brief review of etiology, assessment, and treatment. Behavioral Development Bulletin, 10(1), 36-41. https://doi.org/10.1037/h0100481
Delahook, M. (2019). Beyond behaviors. PESI: Eau Clair, WI.
Eskander N. (2020). The psychosocial outcome of conduct and oppositional defiant disorder in children with attention deficit hyperactivity disorder. Cureus, 12(8):e9521. doi: 10.7759/cureus.9521. PMID: 32905151; PMCID: PMC7465825.
Fooladvand, M., Nadi, M. A., Abedi, A., & Sajjadian, I. (2021). Parenting styles for children with oppositional defiant disorder: Scope review. Journal of Education and Health Promotion, 10, 21. https://doi.org/10.4103/jehp.jehp_566_19
Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: Current insight. Psychology Research and Behavior Management, 10, 353-367. https://doi.org/10.2147/PRBM.S120582
Greene, R. W. (2014). Lost at school. Scribner.
Citation
Bowen-Irish, T. (2024). Strong willed child or oppositional defiant disorder? OccupationalTherapy.com, Article 5737 Available at www.occupationaltherapy.com
