Mr. and Mrs. Lahud have come to the clinic to initiate family therapy. The whole family is under stress because their youngest daughter, 10-year-old Elia, loses her temper “almost constantly,” the par

Mr. and Mrs. Lahud have come to the clinic to initiate family therapy. The whole family is under stress because their youngest daughter, 10-year-old Elia, loses her temper “almost constantly,” the parents say.

“In fact, she seems to be always seething under the surface, even when she’s laughing and seeming to have a good time, just waiting to explode. She argues about the simplest things you can try to give her choices, like, instead of saying, ‘time to get dressed for school,’ you might say, ‘Elia, do you want your green sweater or your yellow one today?’ She just starts screaming and says, ‘You can’t tell me to get dressed!’ And she’s ten.”

Jaival, their new therapist, asks, “Can you tell me how often, on average, you’d say Elia loses her temper? Can you make an average guess at, say, how many times a week?”

Elia’s mother says, “It would be easier to estimate how many times per day.”

Mr. Lahud nods, “Yes, I’d say about 18 times a day, at least once for every hour that she’s awake.”

“And that’s on a daily basis?” says Jaival.

Both parents nod without hesitation.

“How long has it been like this?”

“Well,” Mrs. Lahud tilts her head. “She was always kind of a fussy baby. She’s never slept much and has just kind of always thrown tantrums and never stopped.”

Jaival takes some notes and then asks, “Is there anything else about her behavior that fits a pattern that’s fairly long-standing?”

Mr. Lahud sighs. “It just feels like she wants a big fight, then blames everyone else for something that she started-even when it’s clear no one else is even participating in the fight. It’s getting to be really hard on the other two kids because she just never lets up from the time she wakes up until late into the night; she tries to annoy us and them pretty equally, and now they’re having trouble with her at school too. She’s not getting along with other kids there either.

“We’ve tried positive reinforcement, like a sticker chart for good behavior—”

“-but after a while,” Mrs. Lahud adds, “We just took it down. The other two kids would have rows of stickers, but she defies even the simplest of rules, so she’d have maybe one or two stars to their eight or ten. It started to feel like the sticker chart was just making her feel worse about herself. Her teachers say the same thing.”

Mrs. Lahud’s eyes fill with tears. “We don’t know what to do any more. I feel sorry for her. We can’t help feel that this is not the ‘real’ her, if you know what I mean.”

She looks at her husband, who nods and squeezes her hand.

“She does some pretty mean, spiteful things to ‘get even with everyone.'” Mrs. Lahud continues, “but then the other night, she was quiet and thoughtful when I cuddled with her at bedtime, and while we were alone, she whispered, ‘Mom, why does it have to be so hard to be good? It’s really hard.'”

She breaks down and cries, and her husband hugs her.

1. Jaival meets with Elia subsequently, and though she is very charming and intelligent at first, she does make an effort to annoy him, but he doesn’t take the bait. The next day, with her parents’ permission, the school counselor also calls Jaival, asking if she can share some concerns of her own, which confirm for Jaival that Elia’s parents have pretty accurately described her behavior. Subsequent testing does not reveal a psychotic or mood disorder, and Jaival initially makes a tentative diagnosis of “oppositional defiant disorder.” Do you agree or disagree? What criteria would you cite to support your opinion?

2. What can cause oppositional defiant disorder?

3. Over a period of years, Elia continues to see therapists; and as adolescent hormones are added into the mix, times get a little rougher for her and her family. What kinds of comorbidity might she be at risk for?