One of your jobs as a parent is not nodding in agreement when something doesn’t make sense to you. For example, say that your son, who throws some real tantrums and who is having school difficulties, is being evaluated by a psychiatrist. The psychiatrist asks you about the frequency and volatility of the tantrums. You reply, “They happen all the time, but only with his two older brothers.” The psychiatrist replies, “Oh, those don’t count.”
You could nod your head in agreement, signaling that you agree that those tantrums of course wouldn’t count. Or you could get suspicious and wonder, what sort of thing is a “mental disorder” if some tantrums count and others don’t? You may think that I’m joking that tantrums with siblings somehow don’t count enough when a child’s tantrums are being added up. But that’s the fact.
Here’s the exact language from the DSM-5, the shopping catalogue mental health professionals employ to provide labels. The DSM-5 defines oppositional defiant disorder as, “A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.”
If all of your child’s furious outbursts are with siblings, he has no mental disorder. Add one grown-up to the mix, or one of his fellow students in class, and now you do have a mental disorder. Think about what this way of conceptualizing a mental disorder must mean. It must mean that a tantrum per se, even a zillion of them, doesn’t indicate a mental disorder. If tantrums, defiant behavior, vindictiveness, irritability, and the other so-called symptoms of a mental disorder actually signaled the presence of a biological illness, disease, or disorder, then all such incidents should count in the tallying. Shouldn’t they?
Let me repeat this. You say to your child’s psychiatrist, “All of my son’s terrible tantrums are with his siblings.” “Then he doesn’t have a mental disorder,” he replies. “Sounds like a behavior problem.” “Oh, I forgot,” you add, “once in a while he’s also defiant with my husband and me.” “Ah! Now it’s a mental disorder.” You could nod, since a fellow in a white coat just made a pronouncement. Or you could ask, “Please explain that to me.” What could his explanation possibly sound like? Try to make one up that sounds plausible to you.
Next the psychiatrist says the following funny thing to you. “How long has this been going on?” “About five months,” you say. “Ah,” he replies, “then it’s not a mental disorder yet. Come back in a month.” “But it’s a real problem for us!” “Yes, no doubt it’s a real problem. But it’s not a mental disorder, not until he displays the symptoms for six months.” You could nod and say, “Oh, I see. Okay.” Or you could ask, “Please explain that to me.” What could his explanation possibly sound like? Try to make one up that sounds plausible to you.
Next you mention the following. You say, “By the way, we come from a culture where pretty much everyone throws tantrums all the time.” “Ah,” the psychiatrist murmurs, disappointed. “Then your son doesn’t have a mental disorder.” “But we want him to stop his tantrums!” “No doubt. You certainly have a problem. But if tantrums are normal in your culture, he has no mental disorder. Maybe your culture has the problem!” Again you could nod and say, “Oh, I see.” Or you could say, “Please explain that to me. Isn’t this a biological matter, this mental disorder thing? Or are you saying it’s just a cultural thing?” What could his explanation possibly sound like? Try to make one up that sounds plausible to you.
Your child’s tantrums are real. They constitute a genuine problem for him and for everyone involved. Let me repeat that. Your child’s behaviors are real. I need to say that three or four times because you may be thinking that I am saying that the behaviors are not real or do not exist. They are real and they do exist. What I am saying is that no set of behaviors, no matter how much they disturb us, can be called a pseudo-medical-sounding mental disorder or mental disease just by adding up the behaviors and saying, “That’s a lot.” That’s absurd and illegitimate.
The first question you must ask yourself is “What’s going on?” Can that be adequately answered? Probably it can’t. Who can say why exactly a defiant child is defiant? But as you begin to investigate the various explanations that try to account for these behaviors, you will begin to sense what might be going on. Is it possible that your particular reward-and-punishment system might not be working? Is it possible that you’re looking at developmental delays that are frustrating your child? Could it be that your child’s problem-solving skills are underdeveloped? Is your child playing out some family chaos or crisis? You may not be able to discern what is going on but you can certainly educate yourself as to what might be going on.
The second natural question is, “Given these various possibilities, what might help?” The “might” in that question is very important. Can it make any sense to hope for an answer that comes with a guarantee? Even if you’re feeling desperate and even if you can’t tolerate what’s going on, there is nothing you can try that could possibly come with a guarantee. But that doesn’t make them not worth trying. A change in how you parent might make a huge difference. A change in family dynamics might make a huge difference. A change in how you relate to your child might make a huge difference. Efforts of this sort must be worth your time, mustn’t they?
It is convenient to claim who a child displaying certain behaviors has the mental disorder of oppositional defiant disorder. That takes everyone else but the child off the hook. But to agree with that claim, you are obliged to agree that the criteria used to apply that label make sense to you. Do they? If you look at them and think about them, I doubt that they will. Then you will be thrown back on not knowing for sure what’s going on with your child and forced to try things, like changing how you deal with your child, that are effortful and that come with no guarantees of success. Doesn’t that sound like the necessary, legitimate way?