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An Interview with Keith Sutton, Psy.D. on Oppositional Defiant Disorder (ODD)

David Van Nuys, Ph.D. Updated: Jul 2nd 2009

download this podcast read the transcript

Keith Sutton, Psy.D.In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Keith Sutton, Psy.D. on Oppositional Defiant Disorder. Dr. Sutton is a California Bay Area based Psychologist who has specialized in family therapy, treating parents and children who are experiencing psychological or emotional difficulties through his private practice partnership with Jim Keim, LCSW (a student of Jay Haley, one of the founders of modern family therapy). Listening to the interview, it quickly becomes clear that working with children and families is a true vocation for Dr. Sutton, not just a job. Prior to training as a Psychologist and family therapist, Dr. Sutton worked with children and families for many years across multiple settings, including shelters, residential treatment centers, psychiatric hospitals, wilderness treatment programs, and the like.

Dr. Sutton starts by talking about the nature of Oppositional Defiant Disorder. He notes that late childhood and adolescence are all about the process of individuation, and that to some extent all children are somewhat defiant; that some level defiance at this age is age appropriate and even healthy. ODD occurs where normal defiance takes on an extreme character, resulting in children having problems functioning at home or at school, and at times posing risks to their own safety or to the safety of others. ODD children are quick to lose their temper and to talk back to adults; they commonly refuse to comply with adult commands; they annoy people intentionally, and are touchy, resentful, easily annoyed, spiteful and vindictive.

Dr. Sutton contrasts the tone of disobedience characteristic of ODD with that other common childhood diagnosis, Attention Deficit Disorder or ADD/ADHD, noting that ODD children are typically focused on the process of being defiant itself and care less about the outcome of the conflict they create, whereas ADD/ADHD children are typically more interested in creating a particular outcome for themselves and much less interested in the process of conflicts which may arise as a result of their pursuit of their desired outcomes; they are not truly motivated to pick a fight. As an illustration of the difference between process and content orientations, he offers the famous Japanese Tea Ceremony, which is an elaborate and formal, very process oriented operation which lasts for several hours. Though the tea ceremony does end with a drink of tea, it is much more about the mood that is created during the process of preparing the tea. Anyone interested in actually obtaining a glass of tea quickly (e.g., someone with a content orientation) would be in agony sitting through that ceremony.

Dr. Sutton talks about an important Family Systems concept, namely the IP or identified patient. It is common for parents to bring their children into therapy and suggest that there is something wrong with the children (e.g., to identify the children as the patient). The concept of "patient" brings with it a set of baggage and assumptions, one of which is that a child can be separated from his or her environment and considered accurately in isolation of that environment. In the family systems manner of thinking, which is ecological in nature, there is no such thing as a part which is truly separable from the whole that part belongs to and that assumption that a patient can be separated from the larger system is considered to be an illusion. A truer view on the situation is that the family itself, which is a system of interacting people in different roles, is having the problem; that the problem is located in the interaction space between people within the family; and that the resolution to the problem will involve working with the entire family to alter the interactions that are occurring so that they are less problematic. Ultimately, ODD is less a problem that a child has and more a statement about a mismatch between parents' parenting style and the needs of a particular child.

Dr. Sutton briefly talks about contributions to the development of ODD. He notes that children of depressed parents are at increase risk of the diagnosis, as are children whose families are going through a significant crisis such as divorce, economic hardship, bullied children, and children with mood problems such as depression, which can take the form of irritability. He also notes that sometimes there is no precipitating crisis and that ODD comes about simply as a mismatch between parental and child temperaments. Though feisty children are challenging to raise, they may become excellent trial lawyers or business leaders as adults, he notes. The feisty temperament is not a bad thing in itself, but rather something that is simply difficult to manage for many parents.

The interaction dynamic at the heart of ODD involves children's need for limit-setting. ODD is about who is in charge of the family and setting the agenda. That children feel the need to step up and challenge the adults in their lives for dominance of the family unit may speak to those children's feisty temperament, but it also may speak to children's anxiety upon finding themselves without enough limits set upon them to help them feel safe. The idea here is that as children become more anxious about not having limits set upon them appropriately, they become more likely to act out, either to force the adult to step up and set more limits, or to step up themselves when faced with an 'incompetent' (in the child's view) parent.

It's not the case that children desire merely to be controlled; instead, they desire a balance between an appropriate level of control and an appropriate level of caring and warm loving interaction. Dr. Sutton talks about parenting styles using a two dimensional model to distinguish four broad categories of parenting strategy. One of his dimensions is parental warmth, which may vary from high to low. The other dimension is parental control, which may also vary from high to low (Readers may be interested to note that these are the same two dimensions used by Psychologist Lorna Smith Benjamin's SASB system for describing interpersonal behavior). Parents who are high on control and low on warmth are described as Authoritarian in approach. Kitty-corner to Authoritarian parents are Permissive parents who are high on warmth and lower on control. Parents who are low in both warmth and control may be thought of as Neglectful. Finally, parents who are high on both warmth and control may be thought of as Authoritative (although true Authoritative parents are not too extremely high on these dimensions). According to Dr. Sutton, it is the Authoritative (high warm, high control) parents who typically best provide children with what they need, and the Authoritarian, Permissive and Neglectful parents who have a harder time doing that, and who are consequently more likely to experience children's defiant behavior.

Dr. Sutton notes that many parents have a great deal of difficulty understanding how to be simultaneously both warm and limit-setting at the same time. He finds that many parents try to be loving until they reach their limit, and then become controlling and withdraw their love from their problem child. He works with parents to help them understand how to continue to be loving even while setting necessary limits.

In sessions, Dr. Sutton works with parents and the family to help everyone understand the nature of the therapy approach. He works to dispel blame from both the identified patient (e.g., the problem child), and from the parents, who typically themselves feel blamed by peers and their own parents for not being good enough parents. He teaches the family systems view of the problem as systemic in nature and not located in the individual faults of any single family member. He also works with parents to understand that while there is every reason to expect that the family situation will improve, there isn't any single "silver-bullet" intervention that is going to do the trick. Rather, the family will explore multiple interventions and suggestions, most of which will not work, but some of which will. By setting expectations early on, he helps to create realistic expectations for what is possible to achieve.

Dr. Sutton typically urges parents to do self-care and respite activities to counter their feeling of burnout and fatigue which is generally evident as families make their way into his office. Such activities might include establishing (or reestablishing) a 'date-night' routine, exercising, taking mindfulness or meditation classes, or finding other ways to relax and replenish themselves, etc. He notes that parents' ability to express love and warmth for their children is the most powerful behavior change agent in existence, so they need to do what they need to do in order to have the energy to feel loving towards their children again.

Dr. Sutton also educates parents regarding the buttons that their children push to get a rise out of them so that they can learn to not provide that rise. He helps parents to learn how to better monitor their own emotional reactivity so that they can learn to temporarily excuse themselves from interactions with their child which will otherwise quickly degenerate into screaming matches. As Sutton describes it, the goal is to help parents move from being the bull and locking horns with the child, to becoming the bullfighter, and moving out of the way as the child/bull charges.

Dr. Sutton dispels the myth that family therapy sessions involve the entire family meeting repeatedly for multiple sessions. In his practice, early sessions with the entire family quickly give way to sessions with various members of the family. His goal is to understand the interactions (e.g., the dynamics) that occur between family members that constitute the problem, and then to understand the motivations and desires of each member of the family, so that these motivating factors can be tapped into later when trying to undo the seemingly intractable conflicts family members have found themselves at. He also wants to understand more of the positive behaviors the child may be offering, as well as the negative behaviors. This latter information is important, as parents will typically focus on what is going wrong, and ignore what is going right. Dr. Sutton works to educate parents to pay attention to and reinforce strongly what their child is doing right, so as to strengthen that behavior.

As parents recharge themselves and learn how to take healthy control over their family interactions, Dr. Sutton cautions them to watch for the "extinction burst"; a period of time during which defiant children will increase their defiance behavior dramatically. In some cases, increased defiance may get to the point where it is manifestly unsafe, such as when children may cut on themselves, threaten suicide, or run away from home. The appearance of such behaviors will require special consultation with the therapist, and possibly medical attention. Generally, the extinction burst will settle down as children learn that they can trust and rely upon the new limits set on them.

As the interview winds down, Dr. Van Nuys asks Dr. Sutton what he thinks of the show "Super Nanny". Dr. Sutton remarks that he likes that show very much as Jo Frost (Super Nanny herself) teaches parents to offer their children a similar balance of limit setting and loving interaction that he recommends. He emphasizes the need to really express a lot of love towards children, as ultimately, it is children's loving regard for their parents which fuels their willingness to respect parental wishes. This is particularly true as children become adolescents. Sutton remarks, "When kids are young you are their manager. At some point in time you get fired. Then, your task is to get rehired on as their consultant".

Links Relevant To This Podcast:

About Keith Sutton, Psy.D.

Keith Sutton, Psy.D.Dr. Keith Sutton is a licensed psychologist in private practice in San Francisco and San Rafael, CA. He has worked with teenagers for 11 years prior to and during his training as a psychologist in settings such as teen shelters, a residential treatment program, a drug and alcohol outpatient program, a wilderness program, schools, and community clinics. He was recently elected as the President of the Association of Family Therapists of Northern California. In addition to working with teenagers, he also works with individual adults, couples, and does neuropsychological assessments for learning problems and ADHD. Dr. Sutton uses a number of therapies including Cognitive Behavioral Therapy, Eye Movement Desensitization Reprocessing, Brief Strategic Family Therapy, Strategic Family Therapy, Schema Therapy, Narrative Therapy, and Solution Focused Therapy.

He and Jim Keim, LCSW, the former director of training for Jay Haley & Cloe Madanes, the creators of Strategic Family Therapy, have started the Bay Area Oppositional and Conduct Disorder Clinic which is part of the Institute for the Advancement of Psychotherapy. Here they provide therapy to families with oppositional children and provide live training to therapists looking to build their expertise with this population. Therapists receive "live" supervision where a team watches from a one way mirror and calls in to give the therapist suggestions during the session. It is a very effective way to train practitioners and based on the Mental Research Institute model.

    Reader Comments
    Discuss this issue below or in our forums.

    RIGHT REWARD - ANNE - Dec 16th 2009

    I found that one must ask a child what he wants for a reward not what you want to give for a reward!  True praise, giving attention (ask them to help you, classroom jobs), encouragment, consequences, talk and explain why and what they should do, warnings, time out (put them by themself), being constant, telling them they control what they do and it is their choice, never giving up, loving each student no matter what!!!    I taught over 35 years in the center of a large city and I found these worked for me.

    school setting - - Oct 28th 2009

    I would love to know how to deal with such children in a school setting. Consistence, rewards I know! But the child is not complying! Help!!

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