HELP FOR PARENTS WITH STRONG-WILLED, OUT-OF-CONTROL CHILDREN AND ADOLESCENTS

Education and Counseling for Individuals Affected by Oppositional Defiant Disorder and ADHD

Treatment & Management for Disobedient Children

OPPOSITIONAL DEFIANT DISORDER (ODD) is defined as a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months. Behaviors included in the definition include the following:

• actively defying requests
• arguing with grown-ups
• being resentful, spiteful, or vindictive
• being touchy, easily annoyed or angered
• blaming others for one's own mistakes or misbehavior
• deliberately annoying other people
• losing one's temper
• refusing to follow rules

OPPOSITIONAL DEFIANT DISORDER is usually diagnosed when a youngster has a persistent or consistent pattern of disobedience and hostility toward moms and dads, educators, or other grown-ups. The primary behavioral difficulty is the consistent pattern of refusing to follow commands or requests by grown-ups. Kids with OPPOSITIONAL DEFIANT DISORDER are often easily annoyed; they repeatedly lose their temper, argue with grown-ups, refuse to comply with rules and directions, and blame others for their mistakes. Stubbornness and testing limits are common, even in early childhood.

The criteria for OPPOSITIONAL DEFIANT DISORDER are met only when the problem behaviors occur more frequently in the youngster than in other kids of the same age and developmental level. These behaviors cause significant difficulties with family and friends, and the oppositional behaviors are the same both at home and in school. Sometimes, OPPOSITIONAL DEFIANT DISORDER may be a precursor of a conduct disorder. OPPOSITIONAL DEFIANT DISORDER is not diagnosed if the problematic behaviors occur exclusively with a mood or psychotic disorder.

Prevalence and Comorbidity—

The base prevalence rates for OPPOSITIONAL DEFIANT DISORDER range from 1-16%, but most surveys estimate it to be 6-10% in surveys of nonclinical, non-referred samples of parents' reports. In more stringent population samples, rates are lower when impairment criteria are stricter and when the information is obtained from both parents and educators, rather than from parents only. Before puberty, the condition is more common in boys; after puberty, it is almost exclusively identified in boys, and whether the criteria are applicable to girls has been discussed. The disorder usually manifests by age 8 years. OPPOSITIONAL DEFIANT DISORDER and other conduct problems are the single greatest reasons for referrals to outpatient and inpatient mental health settings for kids, accounting for at least half of all referrals.

Diagnosis is complicated by relatively high rates of comorbid, disruptive, behavior disorders. Some symptoms of Attention Deficit Hyperactivity Disorder (ADHD) and Conduct Disorder overlap. Researchers have postulated that, in some kids, OPPOSITIONAL DEFIANT DISORDER may be the developmental precursor of conduct disorder. Comorbidity of OPPOSITIONAL DEFIANT DISORDER with ADHD has been reported to occur in 50-65% of affected kids.

In some kids, OPPOSITIONAL DEFIANT DISORDER commonly occurs in conjunction with anxiety disorders and depressive disorders. Cross-sectional surveys have revealed the comorbidity of OPPOSITIONAL DEFIANT DISORDER with an affective disorder in about 35% of cases, with rates of comorbidity increasing with patient age. High rates of comorbidity are also found among OPPOSITIONAL DEFIANT DISORDERs, learning disorders, and academic difficulties. Given these findings, kids with significant oppositional and defiant behaviors often require multidisciplinary assessment and may need components of mental health care, case management, and educational intervention to improve.

Risk Factors and Etiology—

The best available data indicate that no single cause or main effect results in OPPOSITIONAL DEFIANT DISORDER. Most experts believe that biological factors are important in OPPOSITIONAL DEFIANT DISORDER and that familial clustering of certain disruptive disorders, including OPPOSITIONAL DEFIANT DISORDER and ADHD, substance abuse, and mood disorders, occurs.

Studies of the genetics of OPPOSITIONAL DEFIANT DISORDER have produced mixed results. Under-arousal to stimulation has been consistently found in persistently aggressive and delinquent youth and in those with OPPOSITIONAL DEFIANT DISORDER. Exogenous factors such as prenatal exposure to toxins, alcohol, and poor nutrition all seem to have effects, but findings are inconsistent. Studies have implicated abnormalities in the prefrontal cortex; altered neurotransmitter function in the serotonergic, noradrenergic, and dopaminergic systems; and low cortisol and elevated testosterone levels.

Clinical Course—

In toddlers, temperamental factors, such as irritability, impulsivity, and intensity of reactions to negative stimuli, may contribute to the development of a pattern of oppositional and defiant behaviors in later childhood. Family instability, including economic stress, parental mental illness, harshly punitive behaviors, inconsistent parenting practices, multiple moves, and divorce, may also contribute to the development of oppositional and defiant behaviors.

The interactions of a youngster who has a difficult temperament and irritable behavior with moms and dads who are harsh, punitive, and inconsistent usually lead to a coercive, negative cycle of behavior in the family. In this pattern, the youngster's defiant behavior tends to intensify the parents' harsh reactions. The moms and dads respond to misbehavior with threats of punishment that are inconsistently applied. When the parent punishes the youngster, the youngster learns to respond to threats. When the mother or father fails to punish the youngster, the youngster learns that he or she does not have to comply. Research indicates that these patterns are established early, in the youngster's preschool years; left untreated, pattern development accelerates, and patterns worsen.

Developmentally, the presenting problems change with the youngster's age. For example, younger kids are more likely to engage in oppositional and defiant behavior, whereas older kids are more likely to engage in more covert behavior such as stealing.

By the time they are school aged, kids with patterns of oppositional behavior tend to express their defiance with educators and other grown-ups and exhibit aggression toward their peers. As kids with OPPOSITIONAL DEFIANT DISORDER progress in school, they experience increasing peer rejection due to their poor social skills and aggression. These kids may be more likely to misinterpret their peers' behavior as hostile, and they lack the skills to solve social conflicts. In problem situations, kids with OPPOSITIONAL DEFIANT DISORDER are more likely to resort to aggressive physical actions rather than verbal responses. Kids with OPPOSITIONAL DEFIANT DISORDER and poor social skills often do not recognize their role in peer conflicts; they blame their peers (e.g., "He made me hit him.") and usually fail to take responsibility for their own actions.

The following 3 classes of behavior are hallmarks of both oppositional and conduct problems: (1) noncompliance with commands; (2) emotional overreaction to life events, no matter how small; and (3) failure to take responsibility for one's own actions.

When behavioral difficulties are present beginning in the preschool period, educators and families may overlook significant deficiencies in the youngster's learning and academic performance. When many kids with behavioral problems and academic problems are placed in the same classroom, the risk for continued behavioral and academic problems increases. OPPOSITIONAL DEFIANT DISORDER behavior may escalate and result in serious antisocial actions that, when sufficiently frequent and severe, become criteria to change the diagnosis to conduct disorder. Milder forms of OPPOSITIONAL DEFIANT DISORDER in some kids spontaneously remit over time. More severe forms of OPPOSITIONAL DEFIANT DISORDER, in which many symptoms are present in the toddler years and continually worsen after the youngster is aged 5 years, may evolve into conduct disorder in older kids and teens.

Treatment & Management—

Given the high probability that OPPOSITIONAL DEFIANT DISORDER occurs alongside attention disorders, learning disorders, and conduct disturbances, an evaluation for these disorders is indicated for comprehensive treatment. Pharmacologic treatment (e.g., stimulant medication) for ADHD may be beneficial once this is diagnosed. Kids with oppositional behavior in the school setting should undergo necessary screening testing in school to evaluate for possible learning disabilities. With the multifaceted nature of associated problems in OPPOSITIONAL DEFIANT DISORDER, comprehensive treatment may include medication, parenting and family therapy, and consultation with the school staff. If kids with OPPOSITIONAL DEFIANT DISORDER are found to have ADHD as well, appropriate treatment of ADHD may help them to restore their focus and attention and decrease their impulsivity; such treatment may enable their social and behavioral interventions to be more effective.

PARENT MANAGEMENT TRAINING is recommended for families of kids with OPPOSITIONAL DEFIANT DISORDER because it has been demonstrated to affect negative interactions that repeatedly occur between the kids and their moms and dads. PARENT MANAGEMENT TRAINING consists of procedures in which parents are trained to change their own behaviors and thereby alter their youngster's problem behavior in the home. PARENT MANAGEMENT TRAINING is based on 35 years of well-developed research showing that oppositional and defiant patterns arise from maladaptive parent-child interactions that start in early childhood.

These patterns develop when moms and dads inadvertently reinforce disruptive and deviant behaviors in a youngster by giving those behaviors a significant amount of negative attention. At the same time, the parents, who are often exhausted by the struggle to obtain compliance with simple requests, usually fail to provide positive attention; often, the moms and dads have infrequent positive interactions with their kids. The pattern of negative interactions evolves quickly as the result of repeated, ineffective, emotionally expressed commands and comments; ineffective harsh punishments; and insufficient attention and modeling of appropriate behaviors.

PARENT MANAGEMENT TRAINING alters the pattern by encouraging the mother or father to pay attention to prosocial behavior and to use effective, brief, non-aversive punishments. Treatment is conducted primarily with the moms and dads; the therapist demonstrates specific procedures to modify parental interactions with their youngster. Parents are first trained to simply have periods of positive play interaction with their youngster. They then receive further training to identify the youngster's positive behaviors and to reinforce these behaviors. At that point, moms and dads are trained in the use of brief negative consequences for misbehavior. Treatment sessions provide the parents with opportunities to practice and refine the techniques.

Follow-up studies of operational PARENT MANAGEMENT TRAINING techniques in which moms and dads successfully modified their behavior showed continued improvements for years after the treatment was finished. Treatment effects have been stronger with younger kids, especially in those with less severe problems. Recent research suggests that less severe problems, rather than a younger patient age, is predictive of treatment success. Approximately 65% of families show significant clinical benefit from well-designed parent management programs.

Regardless of the youngster's age, intervention early in the developing pattern of oppositional behavior is likely to be more effective than waiting for the youngster to grow out of it. These kids can benefit from group treatment. The process of modeling behaviors and reactions within group settings creates a real-life adaptation process. In younger kids, combined treatment in which moms and dads attend a PARENT MANAGEMENT TRAINING group while the kids go to a social skills group has consistently resulted in the best outcome. The efficacy of group treatment of teens with oppositional behaviors has been debated. Group therapy for teens with OPPOSITIONAL DEFIANT DISORDER is most beneficial when it is structured and focused on developing the skills of listening, empathy, and effective problem solving.

Obstacles to Treatment—

OPPOSITIONAL DEFIANT DISORDER and other conduct problems can be intractable. Despite advances in treatment, many kids continue to have long-term negative sequelae. PARENT MANAGEMENT TRAINING requires parental cooperation and effort for success. Existing psychiatric conditions in the parents can be a major obstacle to effective treatment. Depression in a mother or father (particularly the mother) can prevent successful intervention with the youngster and become worse if the youngster's behavior is out of control. Substance abuse and other more severe psychiatric conditions can adversely affect parenting skills, and these conditions are particularly problematic for the moms and dads of a youngster with OPPOSITIONAL DEFIANT DISORDER.

In situations in which the moms and dads lack the resources to effectively manage their youngster, services can be obtained through schools or county mental health agencies. Many states have effective "wrap around" services, which include a full-day school program and home-based therapy services to maintain progress in the home setting. Thus, effective treatment can include resources from several agencies, and coordination is critical. If county mental health or school special education services are involved, one person is usually designated to coordinate services in those systems.

Help for Parents with Oppositional Children and Teens

8 comments:

Anonymous said...

I live in Chester, Virginia and have been dealing with my son since he was diagnosed at age 5. Six months ago he started refusing to take his medication. I should mention he also has been treated for pediatric bi-bolar disorder. He was taking Risperdal, but now refuses any and all medication. His behavior has steadily deteriorated - and I don't think it's just from a lack of meds. I think we've entered rebellious adolescence on top of everything else.



My biggest concern now is that he makes my 10 year old son's life miserable, in addition to mine and my husband's life. I've exhausted all my county resources, i.e. CAST - children and adolescent services team, through which we have had 3 different psychiatrists over the years. The most recent one is a really sweet, elderly man, but again, we get no where now. I can't even get my son to see anyone. I need help and don't know where to turn anymore. I should also mention that it's late, my computer is about to die, my son is over 6 feet tall, and when he's angry, I am afraid for my physical safety.



Please, point me in the right direction. School will start in 5 feets - he will be a freshman. Up until the last 4 months of this past school year he had been in special services since 2nd grade. We finally mainstreamed him and he did really great until the last 3 weeks or so - at which point he was told not to come back to school for the last week of school - that was in lieu of suspending him. Did I mention that he's obsessed with sex - talking about it, insinuating things about it, etc.

Anonymous said...

Your programme is great and it's been a real relief to find something that helps me to put into practice what I know I want to do, but more importantly in the correct order, rather than jumping in with both feet and going from 0 to 60 in too short a time. The fair fighting is amazing and has already made a real difference - they really find it so frustrating and confusing not to be able to push my buttons!

I have been stuck to the website, reading the text and listening to the videos.

Anonymous said...

I am a mother of 18 yrs old son who is repeating grade 9 this year. The child is drinking, smoking and going out with children who are doing the same as him. We tried to talked with him about his future but not listing. He should be finished his school but because of the mentioned matters he is still at school. As his parents we tried to take him to the social workers and phycologist but no improvement. I even took him to the church for help, but it does not work. Now I am struggling to take him to outside boarding school but they are all expensive. My son is lost. He look like he want to change but something is in his mind.

Anonymous said...

Yes, I am so frustrated. My 15-1/2 year old teenager experienced another meltdown twice today. I am looking to help our relationship. He orders me around, makes me apologize, and says aweful things about hurting himself, me and/or another innocent person. Somehow after my second husband's passing, during the last three years my son has displayed more and more anger. He is currently on probation for threatening to stab me in the neck. (I am concerned about his future relationships with girls/women.) I managed to get him calmed down this morning and we left home to run errands. While driving home, we were talking and he started getting upset with me again. I then said "Please don't get upset with me again." The word "again" set him off. He said I acted like a victim like he was being mean towards me, that I thought he was crazy, and demanded I apologize and claimed that I was mentally abusing him. He is very sensitive with any of my words. I try to be sensitive when talking with him, yet today I lost my patience and screamed back at him while we were in the car when I was driving. He dug his fingers hard and deep into the inside of my arm. It created must pain and I asked him to let go, but he just dug in hardened, no broken skin just redness and most likely brusing later as I bruise after the fact. Yes, he is ordered to see a psychiatrist and he managed to "pull the wool over her eyes" like he does with many high-level professionals. He is very intelligent, articulate and I feel he manipulative too. He can be so sweet and than the other side of him is totally the opposite. The psychiatrist was only planning to see him once and diagnosed him with "Adjustment Disorder." The court has also ordered him to anger management and me to accompany him to learn what he is taught. I am to pay for both him and myself at $295 each. I am currently looking for a family counselor, and I have found a therapist for myself to begin next week. I am having trouble getting the family counseling therapists to return my many calls. I am told they are extremely busy.

Anonymous said...

I am now a single mum with four children and they have had to move from a farming situation to the city and my 12 year old son who is a very capable young man, is frustrated. I find that he is closed off to me, doesn’t listen, is disrespectful, has started to lie and go behind my back. He has good grades at school and things are improving there but at home, he is difficult, teases the other kids and I feel that he is so disjointed from the family. We recently took facebook and skype from him because he was obsessed with it and only gave it to him under strict conditions that I had full access, he tried to set up another account which I found out about and made him deactivate and he was grounded for a week. Once the punishment was completed he was allowed back on the original account were I had full access and then we received a complaint from his girldfirends parents that his chat online was a little too racy and could he stop communicating and the relationship was to end, which was fair enough, personally I thought they were too young to be carrying on the way they were. His father insisted the FB account be deactivated for a while and we thought that was the end of it until yesterday when he reactivated the other account, but I found out, rang the girls parents as she had also reactivated her and as a result of the mis trust I have deactivated the accounts for another month and grounded him and he is on extra chores. His attitude is terrible, he is grumpy, looks at me like he hates me, teases the other kids, talks with distain in his voice and I just feel so sad. Am I being too tough, what am I missing? Brandon is a kid that has had every opportunity, more than the others, we go to all his sports, support everything he does, encourage him to do more and I know he misses his Dad and the farm, his independence. I give him lots of independence at home, he goes out most days after school unless their is sport on, all I want is a connection, the ability to laugh at my son, enjoy him and him I and not think, thank god he has gone out or I don’t like him right now! I feel so mean. I resent my ex husband for splitting our family and putting us in this position, although I keep things very amicable for the kids and don’t argue with him, he has full access to the kids when he is home from work and they spend every second weekend with him. I just feel like I was the one who did nothing wrong in our marriage and I am left picking up all the pieces and dealing with all the crap and he gets this fun happy weekend where he is creating memories with my kids that I don’t get included in and I have no happy times, just the mumdane school run, running kids around to sports etc and cooking and cleaning for them and nagging them.

Anonymous said...

I found the information in one of the companion guides interesting on power struggles “you may win the battle but lose the war” - this is Shennae. No matter how much I reiterate that I’m not trying to control her life, I just want to ensure she’s safe. I brought to her attention that all the guys she’s interested in she may perceive as having power because they’re all basically living in the adult world – ie working and some are driving.

This weekend (it’s now Monday), she hasn’t been home since Friday. She doesn’t have her phone back but she doesn’t seem to care and has told me that she can’t contact me without her phone so it’s my doing.

I spoke with her counsellor, who came here last Thursday to see her, and he told me not to report her as a missing person to the police as this will only aggravate the situation. He told me to do something with her like take her to get her nails done (this was something I was going to do a number of months ago but it didn’t eventuate) but don’t speak about anything heavy. I did this and we had great conversation but it didn’t stop her from leaving on Friday.

This counsellor is appointed by Youth Services which is part of one of our government services - DHS (Department of Human Services).

We are going away for 4 days from tomorrow for school holidays with all 3 and their respective friends. I’ve been trying to keep things calm so she’ll come with us because the boys are so excited about this holiday and I want to be totally present for it. She has agreed to come away but I’m worried this may change. I’ve told her that if she comes away she’ll get her phone back.

I’ve been following some of her activities via Facebook as I confiscated her computer and fortunately she was still logged in. She’s stayed at a few different places and has tried to organise somebody to buy alcohol for her, convince another person to shout her some marijuana because they weren’t interested in indulging in ice or speed.

I’ve had numerous conversations about drugs with her and she has printed information from her counsellor but she’s told me to trust her – she knows what she’s doing. She says that even if she becomes addicted she’ll just go to rehab. She feels that at this age she’s just doing time. Basically waiting to get to an age where she can actually do something. I’ve told her that this time is for continuing her education so she is employable.

My ex and I have been looking into outback teen programs. Most of them appear to be very expensive. This may be our only alternative. Her father was going to take over care of her and he attempted this over a month ago now but couldn’t physically catch her. She told him that she hates him and never wants to see him.

The police won’t bring her home – they’ll only speak to her, Youth Services are giving me contrary advice to yours and my relatives want me to keep everything from her until she gives in.

Anonymous said...

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Anonymous said...

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