My Teen has Oppositional Defiant Disorder: How will DBT Help?

If your teen has Oppositional Defiant Disorder, or ODD, life can be a never-ending power struggle. While it’s normal to have an increase in conflicts with parents during adolescence, teens with ODD are constantly irritable, sarcastic, or aggressive (either verbally or physically). They could be often shrugging off rules and using obscenities or curse words. You may feel like they’re deliberately trying to upset you with their extremely hurtful remarks, and that they’re seeking revenge when they perceive you’ve done something wrong to them.

And this behavior isn’t exclusive to just parents; rather any authority figure they feel challenged by. At school, this behavior can cause fights with their peers and punishments by their teachers. Teens with Oppositional Defiant Disorder are easily angered and become resentful and explosive when things don’t go their way.

Here’s the thing, though: By the age of 16, about 11% of all teens have had or currently have ODD. That is a big percentage of the adolescent population. So if you feel like your teen fits into the ODD category, realize you’re not alone.

If you’ve done any research to find help for your adolescent with ODD, you might have found that a combination of medication, parent training, CBT and Dialectical Behavior Therapy can all treat the condition.

Let’s focus on DBT for now: how exactly does DBT work for adolescents with Oppositional Defiant Disorder?

DBT for Adolescents with Oppositional Defiant Disorder

There are five modules of Dialectical Behavior Therapy skills for adolescents.

  1. Tolerating difficult emotions safely and reduce suffering through reality acceptance (distress tolerance)
  2. Managing relationships effectively (interpersonal effectiveness)
  3. Increasing awareness and focus in the present moment (core mindfulness)
  4. Navigating up-and-down emotions (emotion regulation)
  5. Finding balance between two extremes (walking the middle path)

Each module of DBT will help treat the chronic anger, irritability, and outbursts that your teen displays.

Distress Tolerance Skills

When a child experiences a “no,” disappointment is inevitable. However, teens with ODD become significantly more distressed and angry whenever they don’t get their way. They may curse at you, become belligerent, make threats, throw temper tantrums, and lash out verbally and physically. Dialectical Behavior Therapy’s Distress Tolerance skills will teach your child quick ways to safely defuse their distress instead of blowing up. For example, a teen with ODD might get angry if his mother doesn’t let him play his Xbox one night after dinner, curse at his mom, and then go and use the Xbox anyway. Distress Tolerance skills will prompt him to do other things, instead (such as dunk his face into a bowl of freezing-cold water, run around the block, do a set of pushups, listen to music, engage in paced breathing.) These skills redirect the negative energy that teens with ODD experience into safe expressions of emotion that are ultimately stress-reducing. Distress tolerance skills are important for teens with ODD, since such teens have a hard time accepting limits and consequences for their behavior. With these skills, they can learn how to tolerate the negative feelings that come along with consequences for their behaviors.

Interpersonal Effectiveness Skills

For teens with ODD, and with others close to them, relationships are more stressful than enjoyable. That’s where DBT’s interpersonal effectiveness skills come in. Think of it as Family & Friends Troubleshooting 101. Adolescents learn how to fix their relationships with their parents and those around them. They also learn to prevent them from getting broken in the first place. These prosocial skills are simple, basic and practical. They teach teens how to listen attentively when someone is speaking to them, use basic manners, and be gentle in their tone of voice and body language. There is even a specific skill—DEARMAN—that teaches teens how to ask for something politely and considerately, without demanding it.  Adolescents also learn how to appropriately navigate conflicts. Since most teens with ODD resort to anger or threats when someone criticizes or disagrees with them, DBT teaches them how to evoke empathy and put themselves in the other person’s shoes instead.

Mindfulness Skills

Mindfulness strategies, which promote calmness and self-awareness, are meant to be practiced on a regular basis—in the morning upon waking up, on the ride to school, before going to bed. One example of a mindfulness exercise is meditative breathing. The more an ODD teen practices meditative breathing in situations where he isn’t angry or stressed, the greater chance he’ll use it when he is upset or in a crisis. Other mindfulness skills, such as urge surfing, validation, loving-kindness, teach teens how to become more in sync with their emotions and their body. When teens can recognize the physiological signs that arise when they’re getting angry, they can reign in an explosion before it happens. They learn how to switch from their hot, mood-dependent Emotion Mind to the more balanced Wise Mind.

Emotion Regulation Skills

When we’re not taking care of ourselves properly, we get more frustrated easily. It’s harder to control our emotions. Emotion Regulation skills teach teens how to give themselves the best chances of keeping calm by maintaining their physical health (getting enough sleep, eating healthy and appropriately, avoiding drugs and alcohol) and regularly participating in positive and mastery-building activities that the teen enjoys (such as music, gardening, writing, cooking, going to sports games, etc.) Teens also learn in which situations it is appropriate to use certain emotions. For example, it makes sense to be upset when someone maliciously spreads a false, negative rumor about you in school, but that same anger is not appropriate when your mom says it’s time to get off the computer and go to sleep. Emotion Regulation skills also contribute to helping teens reign in their anger or frustration (or any other emotion they feel as a result of a consequence or limit) before it turns into an explosion or verbally aggressive attack.

Walking the Middle Path Skills

Since teens with ODD struggle with extreme emotions, “Middle Path” skills help them find cognitive balance. For example, these skills teach teens that things don’t always have to be black and white. You don’t have to love or hate every person. School doesn’t automatically have to be “terrible” if it’s not “amazing.” It’s okay to feel angry and glad at the same. It’s fine to be upset at something a friend did while still considering them a good friend. A parent can still try her best to make you happy and make mistakes (just like a teen!). A dad can say no to something you really want and care about you at the same time. There is always more than one way to see a situation; both sides of a conflict can be valid. Middle Path skills help teens see the other side of a story and teach them to refrain from using “all-or-nothing” language like always, never, or totally.

Does DBT Work for ODD?

Dialectical Behavior Therapy is evidence-based: scientific studies have shown it works.

In one study, more than 30 teens with Oppositional Defiant Disorder were given DBT skills-training over a period of four months (one 2-hour session a week, for 16 weeks). In total, the group learned and reviewed all four of the skill sets: Emotion Regulation, Distress Tolerance, Core Mindfulness, and Interpersonal Effectiveness skills. (Many times, Middle Path skills are included in Core Mindfulness). The teens even had weekly homework on the material – generally consisting of ways to apply the skills to their daily lives— to ensure they were absorbing the information and putting it into practice. At the end of the four months of therapy, the teens self-reported a 50% decrease in their negative symptoms. Their caregivers reported a significant increase in positive behavior, too.

Another observational case series analyzed the effect of DBT on several adolescents in Spain. Though the sample size was small, these teens had severe ODD. (One had even thrown a cat out of the window). At the end of 24 individual DBT sessions, their worst ODD behaviors—violence, aggression, threats, and isolation – had been eliminated.

Where to Get DBT Treatment for Your Teen With ODD

Because DBT is a skills-based therapy, your adolescent will need to learn these skills from a DBT-trained therapist.

Individual therapists usually run adolescent DBT-skills groups in their outpatient practice, coupled with weekly individual sessions and coaching, over the course of a year. If your child’s ODD is more severe, an immersive program may be indicated for stabilization.

Depending on the level of your teen’s ODD, these services can be offered at Residential (RTC), Partial Hospitalization (PHP) or Intensive Outpatient (IOP) programs.

Residential Treatment

If your adolescent needs full-time ODD treatment because they cannot be trusted to be safe around themselves or others, they’ll stay in a non-hospital treatment facility that specializes in treating adolescents with ODD. Your child will learn the four core modules of DBT together with other teens struggling through similar issues. Teens participate in skills groups with their milieu peers and receive in-the-moment client coaching, 24/7, whenever they need it. Additionally, contingency management is extremely important when treating ODD teens on the RTC level. This means exposing teens with ODD to new limits, rules, and consequences and having them practice tolerating these new limits. Most RTCs also incorporate family therapy into the weekly schedule. Parents need to receive training to learn how to set these same limits when their teen returns home. Residential treatment often lasts between 30 to 60 days, depending on the disorder and its severity.

Partial Hospitalization Program

In a Partial Hospitalization Program (PHP), teens attend programming at least five hours per day, five days a week. At this level of care, teens receive a full day of treatment but continue to live at home. Partial hospitalization is an effective alternative to residential or inpatient treatment when ODD symptoms do not require 24/7 monitoring. It may be appropriate for those transitioning from an RTC or those who need more structure than an IOP. On the PHP level, teens continue practicing their DBT skills while learning how to accept rules and consequences. Parental support, in the form of multifamily groups and family therapy, helps train parents to set these same limits and consequences with their teens at home.

Intensive Outpatient Program

An Intensive Outpatient Program (IOP) for ODD is a less intensive option than PHP. At the intensive outpatient level of care, adolescents receive a half day of professional treatment. Most teens in IOP are able to attend school and live at home. Intensive outpatient is an effective alternative to residential or partial hospitalization programs. It may be appropriate for teenagers who need more structure than private practice psychotherapy for their ODD. The number of hours in an Intensive Outpatient Program may vary, but generally, teens in IOP receive 3-4 hours of treatment up to four days a week. On the IOP level, teens continue practicing their DBT skills while learning how to live with rules and consequences. Most IOPs incorporate multifamily groups and family therapy, which teach parents how to set firm boundaries and establish structure with their teens at home.

Whether it’s a DBT therapist or teen rehab center; residential treatment, IOP or PHP, get in touch with a Dialectical Behavior Therapy program for ODD today. Let your child start building, as they say in the DBT world, “a life worth living.”

When you need DBT Treatment for DMDD

If your teen’s ODD issues are extremely persistent and chronic, you may want to consider whether your teen has DMDD instead.

While persistent irritability and excessively angry outbursts are present in both ODD and DMDD, it is more severe in DMDD, and occurs more frequently. In DMDD, a teen’s disruptive outbursts must occur at least 3 times a week, for at least a year. A teen with ODD, however, has outbursts that occur on average once a week for at least 6 months. Also, in DMDD the irritability causes damage in more than one setting (e.g. home and school). To learn more about DMDD symptoms, check out our DMDD Parent Guide.