Clinical Cases

Oppositional Defiant Disorder

Last modified on January 28th, 2013

Amy Rothenberg
Written by Amy Rothenberg

Homeopath Amy Rothenberg presents the case of an 8 yr old girl with oppositional defiant disorder and discusses the Cycles and Segments approach to case taking.

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.

 

There are times in childhood when oppositional behavior is quite normal such as in toddlerhood and early adolescence.  But when oppositional and defiant behaviors become the norm, and are ongoing over many months or years, it can be an exhausting drain on child and family alike. If the child is clearly different than age-matched peers in terms of behavior, always pushing the limits, constantly challenging to manage, or downright violent, it may well be that this child or teen would be categorized as a person with ODD. Most children and teens that I have treated with the diagnosis have had their home, social and school lives negatively impacted by their behaviors & families arrive at our office desperate for help and support. In Claire’s case, her parents had begun to feel that perhaps medication was the only answer, though they lived a very healthful lifestyle and did not believe in the idea of psychotropic drugs, especially not for a child.

For easy reference, here is the list of symptoms associated with ODD from the DMSM manual:

  • frequent temper tantrums
  • excessive arguing with adults
  • active defiance and refusal to comply with adult requests and rules
  • deliberate attempts to annoy or upset people
  • blaming others for his or her mistakes or misbehavior
  • often being touchy or easily annoyed by others
  • frequent anger and resentment
  • mean and hateful talking when upset
  • revenge- seeking behaviors

Actual causes of ODD are not known but many parents and care providers will say that this particular child was more difficult right from the start, perhaps there had been a difficult labor, issues with colic, inability to “go with the flow.” There can be co-morbid diagnoses such as ADD, ADHD, learning issues, and mood disorders such as depression or bipolar as well as trouble with anxiety. In the allopathic world, often the recommendations will involve medications that address any number of these psychological or cognitive problems. With homeopathy, we aim to find a remedy which addresses the whole child in all of his or her glory. The additional non medical approaches used in the USA at this time include parent training programs, psychotherapy for the patient as well as the family, cognitive behavioral therapy and social skills training.

 

In terms of Claire, we often see that the child seems unable to help themselves and the behavior could manifest in any setting. In other children’s homes or out and about in public, Claire was entirely unpredictable, unreliable and just as liable to be contrary, difficult, rude or downright violent. She could not be sent to a friend’s house to play any longer as she was not well behaved; other children and parents of other children shied away from her. It was not uncommon for Claire to have a loud, aggressive, totally inappropriate outburst in a store setting or in a local park or playground. She could haul off and hit someone, throw an object, and most commonly shriek bloody murder. All that said, she was also able to muster a sweet demeanor, a real ability to connect and communicate with others. She easily won friends and could talk to almost anyone. In fact, her parents worried about this too. Maybe she did not have the right kind of “screening mechanism,” was too open with strangers and made contact too easily. Regardless, it did seem to me that she had at least some ability to rein in her emotions and actions, and that a remedy along with ongoing consistency of strong parenting would likely see her behavior improve and help her to become a healthier part of her seven member family as well as her community of friends.

 

I did encourage the parents to have their daughter allergy tested, for in some cases I have seen that severe food or environmental allergies can either cause or worsen all manner of illness, physical or psychological. In Claire’s case no allergies were disclosed.

 

What can we expect a remedy to do in this setting for this kind of child? For those with emotional and behavioral issues we can look for remedies, alongside consistent, loving and firm parenting and appropriate school settings, to go a long way in stemming even the most challenging behaviors. That said, I try to never work in a vacuum with such families. I want outside objective therapists to help with both accurate diagnoses and behavioral treatments and most importantly to help with follow-up assessments. For children in this group, we may need to go through a number of remedies as the child shifts and makes progress. We may see regression or new emotional characteristics show up that we will have to look at in context of the whole child.

 

I have helped many families through tough times with difficult children. I have not been successful in helping every one of these kids as much as I would have liked, but I have always been inspired to try my hardest, and by parental patience, resolve and commitment to supporting their offspring. I have also had the great pleasure of seeing difficult children and teenagers evolve into loving, capable and sensitive adults, now, sometimes hard to believe, with children of their own. Where there has been generation after generation of mental illness or alcoholism, ongoing trauma or neglect and abuse we will see the impact on susceptible individuals. Some of these children are born into families; I have also seen an increasing number of children adopted into families from all kinds of backgrounds, many have stories that are hard to fathom. From the neglected to the abandoned to the warehoused children, it is a testament to the human spirit that some of these little ones have made it at all, and a tribute to dedicated families for taking on sometimes very complex children.

 

After spending time with Claire and her parents, I thought about her story, her issues and about her family’s situation. When I first began to prescribe remedies, in the early 80’s, while a student at naturopathic medical school, I was, as many classical homeopaths, prescribing most often on “pattern recognition.” I was always hoping for that “feeling” with patients when I was most certain I had found a remedy that would help. The problem with pattern recognition was and remains that sometimes I could not see any pattern, or perhaps there was a pattern I did not recognize or worse yet, I thought I did, yet the remedy or remedies did not work.

 

Dr. Paul Herscu, my husband and partner in homeopathic practice, originally described Cycles & Segments (C&S) thinking in the early 1990’s and like some new wives, I was resistant to anything he suggested!  But Paul kept at it! I have now been using this approach to case taking and case analysis for the past sixteen years and have been teaching the material for just about as long. C&S affords me an internal consistency and focus which helps me to organize so much homeopathic knowledge. Further, it streamlines both my case taking and case analysis. Ultimately, this improves my ability to help my patients.

 

While I am taking the case of a patient, I create a Cycle of the patient’s complaints. A Cycle is made up of a group of Segments. A Segment is a group of symptoms that represent the same idea. Below, I will describe and illustrate the Herscu Module computer program I use to assist me. However, the underlying philosophy and approach can also be utilized without any computer software.

 

In order to create a Segment, here’s what I do. With each symptom a patient shares, I think to myself, what is that symptom an example of? Are there other examples in their story? I not only think that question, I pose it to the patient or parent of the patient. My orientation is to hear complaints with this understanding. Even as I observe patients — their dress, posture, body language and all the kinesthetic elements I am observing, I am doing so with this in the back of my mind. I let everything I hear and understand, as well as any of my perceptions, filter through this mindset.

 

For instance, if I have a patient with abdominal bloating, I ask what this is bloating an example of.  Perhaps it is an example of fullness and swelling. Perhaps they also have swelling around the eyes or swollen ankles. I would put all these symptoms in one Segment, as they represent the same idea, and then I would look for the best rubrics to represent these specific ideas. I would call the Segment “swelling” or “bloating.” Sometimes we see Segments that include physical body as well as mental, emotional or cognitive concerns. In a section called “swelling,” if it applied, I might also use a rubric like Mind: Haughty. On the other hand, if there was abdominal swelling that was quite firm and hard, I might see that as an example of “hardness,” and would wonder if there were other examples of “hardness” in the patient’s story, such as hard nodules in the glands or tendency for forming hard stools. Perhaps the person was also very shut down emotionally – another example of hardness. So conclusions about understanding any particular symptom, i.e. any generalization about a Segment, is always context dependent and, as such, relies strongly and uniquely on what else is going on in the patient’s story. You cannot predict the way any symptom will fall within the context of the person’s life, but you can make astute observations and you can have such observations inform your questions.

 

In another case, if I have a patient with tremendous discharge, say chronic loose stool or excessive nasal mucous, and they also had issues with outbursts of anger, I could put these seemingly disparate symptoms and their related rubrics in one Segment and I might call that Segment “discharges.”

 

In this way, no symptom takes on disproportionate measure, and I am sure that I am looking at the overall tendencies of the patient. I no longer worry that I will not perceive or remember exactly the correct rubric, because I understand the whole concept of the patient’s pathology. I can also trust that the remedy that will prove helpful to the patient will come through the repertorization. In this way C&S liberates the homeopath. I have felt that sense of liberation in practice and also as I teach other providers. No longer is there the stress of asking the perfect question at the right time or finding the precise and flawless rubric.

 

RADAR’s Herscu Module reflects this approach and is straightforward to use. With most all my patients, I repertorize on my laptop as I take the case. After an initial period where I work to connect with the patient, which includes explaining my approach a bit if they are interested, I can be found clicking away as we speak. I am not saying it is easy to do this; i.e. taking the case, staying connected to the patient and remaining grounded myself, grouping symptoms according to Segments as they are flying at me, moving Segments around to put them in a logical order that reflects the patient’s life, thinking about rubrics, taking adequate written notes AND use the homeopathic software. But as a long-time and competent “multi-tasker,” I love it! The program also allows for easy movement of rubrics, moving whole Segments and seeing what remedies are coming through as I go.

 

Like many others who have come along on this strange ride of becoming computer literate, it is reminiscent of playing a musical instrument. The computer becomes a kind of outgrowth of my thinking. As many of our patients have computers on or nearby through much of the day and have developed some facility with the laptop, patients do not seem to mind. But if that does not work for you, not a problem! Take the case and repertorize afterwards.

 

Using C&S thinking during casetaking, even a beginner with a couple of years of solid, dedicated homeopathic study, becomes able to take a cogent and organized case. C&S makes it simpler to analyze the information gathered from the patient’s story. Using their own observations and perceptions, even my greenest students repertorize with skill, and come up with perhaps 6-10 possible remedies. This is the right direction for our profession. From there, even most beginners can cross off 2-3-4 remedies and then move to comparative materia medica to help inform their decision on how to choose the best possible remedy for the patient. Also there is now a short list of other possible remedies to consider at the time of the first follow-up visit. The homeopath will not be starting from square one. The randomness I once felt in remedy selection has disappeared.

About the author

Amy Rothenberg

Amy Rothenberg

Dr. Amy Rothenberg is a homeopath and naturopathic physician, writer, teacher and co-director of the New England School of Homeopathy. She was the long time editor of the New England Journal of Homeopathy and is the author of The A Cappella Singer Who Lost Her Voice and Other Stories from Natural Medicine. She teaches Cycles and Segments with her husband Dr. Paul Herscu and lectures all over the world.

3 Comments

  • Amazing! My 21 yr old son was diagnosed with this as a child after a number of inaccurate diagnoses with poor response to medications. He is living with his grandparents out of state now and goes to a community college but I still see many of the same cycles and segments in place when he visits or I talk with him on the phone. I’ve always felt no one understood him as well as I did and I found your recommendations helpful in continuing to guide him into his adult self. He refused to take the psychotropic medications on a regular basis and now I’m happy for that. We shall see what happens next in his life and if there is a qualified naturopath near him in IN. Thank you so much! I will definitely be looking into more into the RADARs Herscu Module!
    Mary

  • Dear Amy
    What a fantastic and encouraging case. Thank you for posting.
    I am having a blank space where the Cycles & Segments module should be — can this be remedied.
    Still a great case though.

  • My son now 11, shows identical symptoms and last assesment was diagnised as ODD, at the same time not doing well in his exams, will be starting with his LD assesments soon however I always feel there is more than LD to him the whole house and routine goes haywired, NEED HELP badly………….

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