Psychotherapy for Oppositional-Defiant Kids with Low Frustration Tolerance—and How to Help Their Parents, Too

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• ODD and Children's Frustrations
• ODD and Low Frustration Tolerance
• How Parents Make it Better or Worse
• The Argument Trap!
• The Overly Helpful Parent
• Psychotherapy with ODD Children and their Parents
• Making Use of the Therapist's Experience and Personal Reactions
• Questions to ask Parents
• References

Childhood temperament is the elephant in the living room of child psychotherapy. Just as the influence of substance use and abuse on clients' behavior problems was often minimized by psychotherapists before the 1970s, the importance of temperament in children's behavior problems is becoming an increasingly essential part of child and family therapy.

After 30 years of working with children and parents, I am convinced that, barring developmental disorders or a major family tragedy, most children who come to therapy have higher-maintenance temperaments (i.e., frequently described as difficult, spirited, or challenging) that frustrate typical parenting approaches.¹ Some parents are unable to effectively deal with certain children who try their patience despite having no such difficulty with their other children. Here I will focus on one aspect of childhood temperament, frustration tolerance, its relationship with Oppositional Defiant Disorder (ODD), and how such concerns can be worked on in therapy with children and their parents. I will also examine the important role played by the therapist's inevitable personal reactions in the therapeutic process.

ODD and Children's Frustrations

When I worked with James R. Cameron, Ph.D. at the Preventive Ounce², we observed that children with low frustration tolerance are at risk for becoming oppositional. We saw that parents often responded to these kids in ways that exacerbated their problematic behavior. ODD has also been related to the child's temperament and the family's response to that temperament. This model helps therapists work with the child's temperament, the parent's style, and the interaction between the two.

In the same vein, Barkley³ states that "children who are easily prone to emotional responses (high emotionality) are often irritable, have poor habit regulation, are highly active, and/or are more inattentive and impulsive and appear more likely . . . to demonstrate defiant and coercive behavior than are children not having such negative temperamental characteristics." He also notes that "immature, inexperienced, impulsive, inattentive, depressed, hostile, rejecting, or otherwise negatively temperamental parents are more likely to have defiant and aggressive children."

DSM-IV-TR⁴ (2000) and ODD

• ODD . . . is a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months.
• In males, the disorder has been shown to be more prevalent among those who, in the preschool years, have problematic temperaments (e.g. high reactivity, difficulty being soothed.) ODD . . . usually becomes evident before age 8 years and usually not later than in early adolescence . . .
• The oppositional symptoms often emerge in the home setting but over time may appear in other settings as well. Onset is typically gradual, usually occurring over the course of months or years..Often loses temper, often argues with adults, often actively defies or refuses to comply with adults' requests or rules, often deliberately annoys people, often blames others for his or her mistakes or misbehaviors, is often touchy or easily annoyed by others, is often angry and resentful, and is often spiteful or vindictive.

ODD and Low Frustration Tolerance

Children with low frustration tolerance are adamant in wanting to end the cause of their frustration as quickly as possible. When they are having a hard time with a task (e.g., homework, some tasks they don't immediately understand, or a toy or game that they can't make work the way they want), they find that the best way to eliminate their frustration is to stop trying and do something else instead. If they want to do something and their parent (or another adult) won't let them do it, the best way to eliminate their frustration is to act in ways that might get the adult to change their mind and leave them to their own desires and interests.

It is worth noting that except for being spiteful and vindictive, ODD traits and behaviors listed in the DSM represent how many children usually act when they don't want to do what they are told to do. The children that meet DSM criteria are diagnosed with ODD, but they could also likely be children with low frustration tolerance who are acting oppositionally in an effort to eliminate their frustration. The behavior that a parent or adult calls oppositional may also, in fact, be a child's age-appropriate response to a developmentally inappropriate limit set by the parent or environment.

How Parents Make it Better or Worse

How do parents make their kids' frustration tolerance better or worse? Note that it is important to allow the child to be frustrated with life pressures and stresses rather than preventing age-appropriate frustrations. Indeed, a key task of parenting is to help children gradually take on more difficult tasks so they learn how to tolerate frustration as well as regulate emotional reactions. The work on how optimal levels of frustration relate to learning,⁵ how attachment develops,⁶ and how managing affect in disorders of the self⁷ point to the importance of parents helping children learn how to manage frustration. Clearly, parents make the situation better or worse by how they interact with their child. Parents make things better by setting appropriate limits, managing their own anxiety, reinforcing positive behaviors, and understanding the motivations of the child. Certainly, parents can behave in ways that make matters worse via what I call the Argument Trap and the Overly Helpful Parent.

The Argument Trap!

One way a parent can worsen the situation is by arguing with the child too much when the child doesn't do what he is asked. Here, the parent, after setting a limit for their child, keeps responding to the child's objections in an effort to have the child understand the parent's logic. This attempt to explain the limit and convince the child of its necessity often results in the child becoming more upset. The parent may then even punish the child for not complying with the limit. But since the child's goal is to remove the frustrating limit, as long as the parent and child are arguing, the child can hope that the parent changes their mind. If the parent gives in, the child is being taught to argue again next time. If the parent punishes the child, then the child has an additional reason to blame their parent for not removing their frustration.

To help a child with low frustration tolerance accept limits, the parent needs to let the child complain about the limit and have the last word, even if the last word is provocative. The parent needs to stick to the limit (unless there is good reason to give in) and not try to convince the child to agree with the limit. The child is less likely to keep arguing if the parent is not responding in kind. The parent ideally needs to set a limit, repeat the limit in as calm a voice as possible, suggest alternatives for the child, and then stop talking about the limit. Restrictions and/or time-outs can be helpful in calming the child, but when the child becomes highly agitated, these methods are often ineffective. In this case, the parent's goal is to shift the child from complaining about a limit to finding something else to do since the child can't do what they want. Thus, the argument is avoided, the child is re-engaged in an activity, and the child learns to better cope with their reactions and emotions.

The Overly Helpful Parent

Another way that parents inadvertently increase their children's low frustration tolerance is by helping their children too much when their children are faced with challenging tasks. Parents naturally help their children countless times each day. But low-frustration-tolerance children will often ask for help without trying enough on their own before seeking help. They tend to give up too soon without really testing themselves, and want the adult to jump in and solve the problem or complete the task at hand. When the parent helps too quickly, the child learns to immediately resort to fussing when frustrated, because this yields the desired results. Remember: removing the frustration is the primary goal for the low frustration tolerance child; solving the problem itself takes on secondary importance.

To help the low-frustration-tolerance child persist at a task such as homework, the parent needs to answer the child's questions when the child is able to listen to the answers. The parent also needs to help the child learn skills for dealing with frustrating situations, such as taking a break or dividing up the homework in smaller chunks and doing one part at a time. When children are upset and frustrated, they don't listen well (if at all!) until they have calmed down. The parent's role is to help the child learn how to handle frustrating situations, not to quickly solve the frustrating situation for the child. For example, when a parent has been helping a low-frustration-tolerance child too much with his homework, backing off from helping may lead to the child receiving worse grades for a while. But when a parent takes too much responsibility for getting homework done, the child doesn't take enough responsibility and does not learn how to cope with frustration. It is more important to teach the child to take responsibility and to learn how to do homework than it is to help the child complete any particular assignment.

Psychotherapy with ODD Children and their Parents

My hypothesis for why oppositional behavior develops in this fashion is that

parents who don't understand how to handle typical low frustration tolerance behavior have inadvertently reinforced that behavior many times over many years before that behavior becomes oppositional. Many parents of children who meet the criteria for ODD could actually be diagnosed as having Argumentative Punitive Disorder (or APD—this is not an actual diagnosis, by the way) because they often lose their temper, argue with their children, blame their children for their ineffective parenting, are easily annoyed by their children, and are angry or resentful toward their children. One of the main goals of therapy is to help parents manage their frustration when their children become frustrated. Below, I present several therapeutic guidelines for working with these kids and their parents.

• Who to meet with? Therapists need to work with the parents as well as the children on a constituent basis, preferably every session. I generally meet with the parent (or parents) before I see the child. We discuss what has happened since the last appointment, how to understand what has happened, and how the parent might try to work with the child before the next appointment. Then I meet with the child alone. Sometimes I meet with the parent and child together—after seeing each of them separately—if there is some issue I think we need to discuss.

• Breaking the Cycle of Arguing: Parents need help learning how to avoid being argumentative-punitive. They need assistance finding the middle ground between too many limits/not enough limits and too much help/not enough help. This takes time and work to find an approach that is tailored to particular parents and their child.

• Encouraging Parents: Since one of my therapeutic goals is to increase the parent's ability to help their child gain more frustration tolerance, I continually encourage parents and reinforce their attempts to find more effective ways to work with their child. I keep reminding parents and children that they are meeting with me to learn new ways to deal with their family problems because the way they are handling matters is not working. It is crucial to encourage and engage the child's parent since they are the ones who usually bring the child in, pay for the sessions, and do the majority of the work every day.

• Validation of Parent Frustration: It is also crucial to validate the parents' feelings of exasperation, anger, and frustration. I empathize with the parents and acknowledge that I would feel similarly if I were parenting their children. I explain again how low frustration tolerance works and encourage the parents to handle their children's oppositional behavior differently even when they feel angry, exasperated, and/or frustrated.

• Talking to the Child about being Responsible: I find it helpful to talk with the children (in language that makes sense to them) about being more responsible for what they are supposed to do instead of complaining so much about what their parents are doing or not doing. I often remind children that if they do as they are told, even if they don't want to, their parents are more likely to let them do more of what they want to. Learning how to negotiate effectively with parents is a valuable tool for any child, and particularly for these children.

• How long is therapy? The length of therapy is highly variable depending on the age of the child, the extent of the child's low frustration tolerance, and the parent's ability and motivation to understand how they have been contributing to the problem. If the parent-child dynamic changes quickly and the child is able to respond, treatment may be briefer, but often there are entrenched problems in the family that are best worked on over a longer course of consistent therapy.

Making Use of the Therapist's Experience and Personal Reactions

Working with oppositional low-frustration-tolerance children and their parents has also frequently left me feeling exasperated, angry, incompetent, and . . . you guessed it, frustrated. For instance, when a parent and I discuss at one session how important it is not to argue and yell at the child about homework, and then the parent comes to the next session and reports another escalating homework argument that ended with the child swearing at the parent and the parent calling the child derogatory names, I sometimes feel like arguing and yelling myself. I start thinking: the parent is provoking the child's defiant behavior, the child is not being responsible about homework, I am not facilitating positive change in the family, etc. It is very easy to get sucked into this escalating family system.

I have come to see my reactions to the parent and child as similar to the reactions the parents and child are having to each other. My feeling that I am not a competent therapist mirrors the parents' feelings that they are not competent parents. My feeling of exasperation parallels the parents' feeling of not knowing what to do when their children continue to be oppositional. My angry feelings mimic the children's feelings at their parents' inability to manage their own behavior or their not getting their own way all the time.

Understanding and managing these personal reactions help me understand the child and their parent's frustrations more fully, making my limit-setting and direct intervention more empathic. It also helps prevents a critical or punitive therapeutic approach which mirrors the parent's approach, which is both ineffective and off-putting to the family.

I invite psychotherapists who work with children to consider the possibility that ODD is temperament-based low-frustration-tolerance behavior that well-meaning but uninformed parents have inadvertently mismanaged. I believe that psychotherapists who add this approach to their work with oppositional children will increase their effectiveness and be better prepared to manage their own personal reactions to this most difficult yet worthwhile endeavor.

Questions to ask Parents

Does Your Child Have Low Frustration Tolerance?
There is no valid and reliable test that can definitively determine whether a child has low frustration tolerance. Temperament questionnaires, observation and reflection, comparison with other children's behavior in the same situation, and parents' willingness to examine their own feelings about a child can help parents and therapists reach an informed opinion about a child's level of frustration tolerance. Here are some questions for parents to consider:

• What is your child's temperament? Energetic-positive, energetic-difficult, passive-low energy, easy going?
• Does your child get frustrated more easily than other children the same age?
• Does your child get easily frustrated when you set limits? O, does your child get easily frustrated when you want your child to stop doing what they are doing and do something else instead? (Note: Some children are slow to adapt to transitions, changes and intrusions, and are likely to get frustrated when asked to stop what they are doing and do something else. Their response should not be confused with that of children with low frustration tolerance, who will complain when a limit is set but may generally not complain when a family routine is changed, the day's schedule is changed, or if you interrupt them when they are doing something. Of course, a child can be slow to adapt to changes and also have low frustration tolerance.)
• Do you give in more often than you think you should when your child complains about a limit? Do you find yourself getting annoyed because your child keeps testing limits?
• Is your child able to play alone or with friends in their own room or do they always have to be with you? Do you often tell your child to "go play" while you try to finish a task?
• Has your child's frustration tolerance decreased suddenly? Has something happened recently (e.g., the birth of a sibling, a change in teachers, a death, a divorce, an illness) that could have upset your child and made your child more easily frustrated about things than previously so? If so, your child's frustration tolerance should improve as you both deal with the feelings associated with the event or change that has occurred.

References

¹Chess, S., & Thomas, A. (1989) Know your child: An authoritative guide for today's parents. (New York: Basic Books)

²Cameron, J.R. & Rice, D. (2000). The Preventive Ounce Web Site. www.preventiveoz.org. (Oakland, CA: The Preventive Ounce)

³Barkley, R. A. (1997). Defiant Children, Second Edition: A Clinician's Manual for Assessment and Parent Training. New York: The Guilford Press

⁴American Psychiatric Association, (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. (Washington, D.C.: American Psychiatric Association)

⁵Stern, D. (1985) The Interpersonal World of the Infant. (New York: Basic Books)

⁶Hughes, D. (1998) Building the Bonds of Attachment. (Northvale, NJ: Jason Aronson)

⁷Schore, A. (2003). Affect Dysregulation and Disorders of the Self. (New York: W.W. Norton) 

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