The first time I met eight year old Claire, she was charming and adorable and clearly had an abundance of confidence. Her jet black hair was cut in a pixie and that word described her to a tee. She chattered away with me, legs crossed like a grown-up and was animated and engaging. Pontificating about school, her social group, her siblings and the colors of the rainbow, she clearly loved being the main attraction, even in this doctor’s office setting.
Ostensibly she was brought for the treatment of eczema and for chronic constipation. The skin eruptions were mostly found on the palmar side of her wrists and Claire could really get going scratching there, especially if her emotions were running strongly. She was chronically constipated, having 2-3 bowel movements a week without much urge to go; her mother helped her in this regard with reminders about fluid and fruit intake as well as the occasional dosage of bulking fiber. If the constipation went unchecked, the below described behaviors would worsen.
Once I had completed my initial interview as well as a screening physical, which did not reveal anything out of normal limits, I asked Claire to go spend some time in the waiting/play room area so that I could speak with her mother alone. Claire complied readily and indeed, seemed eager to please, so it was a bit of a surprise to me when, just as soon as the door closed, her mother began to cry.
She described the ongoing and escalating battles with Claire that began the very moment she opened her pretty blue eyes each morning. From getting dressed to brushing teeth to sitting for breakfast, from getting school things ready, to moving out the door on time, Claire was absolutely impossible. She whined. She complained. She mercilessly teased and picked fights with both younger and older siblings. She could shriek for twenty minutes at a time if she did not get her way. She was hypersensitive to everything, any kind of sensory input, noise, light, and touch; she was intolerant to any feedback or criticism, hated changes in weather, foods she did not care for, even the wrong people looking at her. She had the ability to ruin anything, every family outing, every vacation, every concept of a relaxed evening at home—destroyed in the hands of this little pixie. At school she could be angelic one minute, helpful and cooperative and then could change with the slightest perceived provocation to be disruptive, disrespectful and physically inappropriate. The report from school was remarkable for how well she did academically in contrast to how very difficult she could be with adults and kids alike. At both home and in other children’s homes, when a limit was set or she was reprimanded or at other times of stress, Claire could be found in common areas, masturbating. She had showed other girls in her family and neighborhood how they also could do this “thing that feels so good.” They tried not to shame her, their suggestion of “Now that’s something you do in the privacy of your own room,” fell on deaf ears. Perhaps this was the final straw for the parents. They felt their daughter was entirely inappropriate, was acting like a much younger child, that by eight she should know better in terms of all aspects of her behavior.
Both parents were educated and had access to resources. They were well read on positive parenting techniques, excelled at thoughtful communication and had been in all kinds of talk therapy individually, together, with Claire and as a family. They truly felt they had a monster on their hands. They were consciously committed to not making her the “sick” one in the family and were trying with all their might not to “ruin” her, not to “break her spirit.” But the truth was that every technique they tried with her backfired, every kindness they offered was somehow twisted and thrown back at them. She would not hesitate to hit, to scratch her mother; she almost always took a contrary opinion, could fight about anything. It was as if she believed that the rules did not apply to her. The constant discord, fighting, aggressiveness and hyper-emotionality were wrecking havoc on the entire family. When they arrived at my door, they were literally at their wit’s end.
Oppositional defiant disorder was the diagnosis Claire had been given by a pediatric psychiatrist who strongly recommended further therapy as well as a trial on medication. This unique psychiatric diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders is described as, “an ongoing pattern of disobedient, hostile, and defiant behavior toward authority figures which goes beyond the bounds of normal childhood behavior.” I like this definition as it takes into account the fact that most every child is oppositional sometimes especially if tired, hungry, in discomfort or under undo stress. Kids and then teenagers can bicker, fight verbally or physically; they can overtly or quietly disobey, and defy authority figures like such as parents, school faculty and staff, and other grown-ups in their lives. They can break small and large rules in premeditated ways or seemingly without the ability to see the consequences such behavior might garner. They can do things with the expressed idea of hurting others; they can be less intentional in their behaviors but nonetheless, destructive. Unfortunately, as these children get older, the stakes get higher, and they can do more actual damage to themselves or others, both physical and/or psychological.