OPPOSITIONAL DEFIANT DISORDER

Oppositional Defiant Disorder is defined by the DSM-IV as a pattern of negativistic, hostile, and defiant behavior lasting at least six months during which four of the following are present:

1. Often loses temper
2. Often argues with adults
3. Often actively defies and refuses to comply with adult requests or rules
4. Often deliberately annoys people
5. Often blames others for his or her mistakes or misbehaviors
6. Is often touchy or easily annoyed by others
7. Is often angry and resentful
8. Is spiteful and/or vindictive

Additional criteria include the following:

1. The disturbance and behavior causes clinically significant impairment in social, academic, or occupational functioning.
2. The behaviors do not occur exclusively during the onset of a psychotic or a mood disorder.
3. The criteria is not met for a conduct disorder.


These children usually have a pervasive pattern of a negativistic, hostile, defiant behavior which is usually directed toward adults and authority figures. These children usually behave as if parents, teachers, and other authority figures are "the enemy". Temper tantrums, including screaming, crying, throwing objects, thrashing on the ground, refusing to move, and defiance of direction from an adult caregiver are common. These children constantly argue with adults, refuse to comply with requests and rules even when they are in the child's best interest and are obviously very reasonable. These children seem to be constantly angry and resentful. At one time, oppositional and defiant behavior was viewed as an extension of a "conduct disorder". However, recent research has substantiated that this pattern is, indeed, unique and separate from a conduct disorder.

The causes of an Oppositional Defiant Disorder can vary greatly. A good number of these children may have been sexually or physically abused by adult caregivers which causes a good deal of resentment and distrust. Others have simply developed a pattern of controlling and manipulating adults through their defiant behavior. Many of these children have been raised by parents who have been very ineffective at setting and establishing limits.

Whatever the causes, the central issue for the child is a means of establishing and maintaining control of the environment. Many of these children feel that their environment is inconsistent and difficult to control and are fearful that things may happen or change that could cause them discomfort. One of the crucial elements when working with these children is to actively build a level of trust. This is usually done through the following:

1. Consistent eye contact
2. Active listening
3. Unconditional positive regard
4. Warm acceptance in order to increase his or her ability to identify and express her feelings

It is usually futile to engage in a "battle of wills" with an oppositional child who has dug their heels in and is firmly entrenched and determined to get their way. In situations like this, it is often best to allow a cooling down period until the emotional intensity that the child has experienced has subsided. In addition, it is much more effective to use very subtle and indirect cues rather than to "challenge the child" when he or she is acting defiant. There are exceptions to this, however, including instances where the child may harm himself or harm others. In those cases, it would be advisable to provide passive restraint of the child or at least get the child into an area where he or she cannot hurt himself or others. Aside from this, it would be best to allow the child to cool down and then begin the task of helping the child" reason things out". Often giving the child a set of choices and explaining fully the consequences involved may help the child come to realize that their negative pattern is, indeed, self-destructive. It is very important not to show anger when correcting or disciplining these children since, in many cases, the anger may actually reinforce the negative behavior. Discipline should be handled in a "matter of fact" way in order to minimize anger and resentment that the child feels which tend to increase the oppositionalism. It is also often effective to give the child a feeling of control in giving him choices. For example, you may explain to the child if he does not complete his homework, he will not be permitted to do a certain activity until the homework is done and leave the choice up to the child. If the child refuses, that is his or her choice and this should be accepted by the adult caregiver. The consequences, however, should be very carefully adhered to. Again, this should be done in a very matter-of-fact way with no anger on the part of the adult caregiver displayed toward the child. In fact, the adult caregiver should reaffirm their confidence in their child's ability to complete the task. Sermonizing should also be avoided. Explanations should be very simple, straightforward, and within the child's understanding. Keep in mind that these children carry around a good deal of resentment toward authority figures and your goal in dealing with these children is to establish trust and allow the child a feeling of safety and security in their relationship with you. This involves mutual respect and mutual understanding. The adult caregiver, however, does need to be very firm and consistent and needs to follow through with any stated negative consequences to the non-compliant behavior.

LONG TERM GOALS:

1. Markedly reduce the intensity and frequency of hostile and defiant behavior toward adults.
2.Terminate temper tantrums and replace them with calm, respectful compliance with adult directions.
3. Begin to consistently interact with adults in a mutually respectable manner.
4. Bring hostile, defiant behavior within socially acceptable standards.
5. Replace hostile, defiant behavior toward adults with respect and cooperation.
6. Resolve the conflict underlying the anger, hostility, defiance, and need for control.
7. Help the child reach a level of reduced tension more quickly.
8. Improve the child's ability to communicate with adults, including his or her family.

SHORT TERM OBJECTIVES:

1. The child should develop a working relationship with the TSS worker in which he or she feels safe, and comfortable.
2.The child should decrease the frequency and intensity of hostile, negativistic, and defiant interactions with adults.
3. The child should be encouraged to identify and be able to verbalize sources of negative and hostile feelings in an open, accepting, and understanding manner.
4. The child needs to understand the connection between his or her feelings and the resultant behavior.
5. The child will need to increase the frequency of respectful interactions with adults.
6. The child will be able to verbalize recognition of what is and is not acceptable behavior when he or she is angry.
7. It may also be necessary to help the parents develop very clear and firm boundaries. The parents also need to be very clear and consistent regarding behavioral expectations.


THERAPEUTIC INTERVENTIONS:

1. It is very essential with these children to establish rapport. This may take some time initially, depending on how negativistic and resistant the child actually is.
2. Reflect back to the child in a paradoxical interpretation the negative consequences of their oppositional behavior. For example, it would be appropriate to say to the child, "You seem to want your Mom to put you into time out more often. Is that true?". This will shift the focus of control back onto the child which is very important to oppositional children. At the same time, it will force the child to think about the consequences of their behavior which they often miss.
3. It is important to facilitate consistency within the family which corresponds to your interventions as a TSS worker. In other words, the same issues of respect, cooperation, and conflict resolution should be addressed by family members, if possible, in the same manner as with the TSS worker.
4. Assist the child in his or her ability to recognize feelings and learn to express them in constructive ways. Keep in mind that there is no such thing as a bad feeling. There is only bad behavior. Furthermore, we cannot control our feelings. However, we can control our behavior. Learning to channel our feelings into socially acceptable behavioral patterns is an ongoing lifelong task that children need to begin to recognize and start to deal with.
5. Try to probe with the child feelings that are associated with the defiance and help the child make connections between these feelings and the behavior.
6. When possible, ignore the negative and defiant behavior and reinforce compliance with social and other appropriate reinforcers.
7. Make sure the parents are able to clarify and communicate to the child what is acceptable and unacceptable behavior in the family. This also should be communicated to the child in terms of what is acceptable and unacceptable within a variety of settings. The TSS worker can assist by reinforcing these concepts to the child. There should also be a concomitant withdrawal of interactions and privileges when unacceptable behavior is exhibited. These consequences should be short- term and immediate. The TSS worker should also reaffirm confidence in the child's ability to do better next time.
8. Unproductive over-verbalizations to the child should be avoided.