Oppositional defiant disorder involves a recurring pattern of oppositional, defiant, disobedient, and hostile behavior directed toward authority figures. Although this disorder has important clinical relevance, very little is known about it; probably because many specialists consider it as a variant or manifestation of conduct disorder. In this sense, it should be noted that suffering from oppositional defiant disorder increases the risk of developing conduct disorder and manifesting an antisocial personality in adulthood, but it should not be identified with conduct disorder itself.
It is estimated that oppositional defiant disorder has a population prevalence that varies between 2 and 16%. Almost 75% of cases are related to attention deficit hyperactivity disorder, so much so that between 40 and 60% of children diagnosed with attention deficit hyperactivity disorder end up developing oppositional defiant disorder.
Generally, children with oppositional defiant disorder are usually identified from the early age of two or three years since their behaviors are very disruptive, even creating family problems.
Symptoms of oppositional defiant disorder
The Diagnostic Manual of Mental Disorders specifies what the main symptoms of oppositional defiant disorder are :
– A pattern of negativistic, hostile and defiant behavior that extends for at least six months and in which four or more of the following behaviors are present:
- He gets angry and throws tantrums
- Argue with adults
- Actively defies adults or refuses to comply with their demands
- Deliberately bother other people
- Accuses others of their mistakes or bad behavior
- Is susceptible or easily bothered by others
- Angry and resentful
- Is vengeful
– A clinically significant deterioration in social or academic activity is evident
– Behaviors do not appear exclusively during the course of a psychotic disorder or a mood disorder.
The essential difference between oppositional defiant disorder and other types of dissocial pathologies is that these children do not violate the laws or the fundamental rights of others. In the same way, the child does not steal and does not display destructive, cruelty or intimidating behavior. The definitive presence of any of these forms of behavior would exclude its diagnosis.
What are the causes of oppositional defiant disorder?
The precise cause of this disorder is not known but there are two main theories that try to explain why it appears. Developmental theory suggests that difficulties begin when children are between one and two and a half years old, mainly because they have difficulties learning to separate and become autonomous from the person to whom they are emotionally attached. Thus, “bad behaviors” would be an extension of normal developmental issues that have not been adequately resolved in the first years of life.
On the other hand, learning theory indicates that the negative characteristics of oppositional defiant disorder are learned attitudes that are nothing more than a reflection of the effects of negative reinforcement techniques used by parents and authority figures. Thus, it is thought that the use of negative reinforcement increases the frequency and intensity of oppositional behaviors in the child, who in this way manages to attract the attention of adults and obtains the desired interaction.
In particular, I consider that one theory does not have to exclude the other and in addition, other causal factors must be understood such as the personality or temperament of the child (normally stronger and more energetic than that of his or her contemporaries) and the development of stressful events such as divorce between parents, family problems or illnesses.
In fact, there are several specialists who point out that a strong temperament is at the basis of oppositional defiant disorder, stressful events can act as a trigger for the disorder while the attitudes of parents and the control they exercise over the rebellious behavior of children are the key factor in giving rise to disruptive and challenging behaviors.
When this disorder is not resolved, serious school problems usually appear in adolescence because children are particularly resistant and unpleasant, presenting difficulties both in relationships with teachers and friends.
Treatment of oppositional defiant disorder
It is worth clarifying that in many cases the treatment of oppositional defiant disorder involves not only psychotherapy but also pharmacology, using selective serotonin reuptake inhibitors and other medications such as methylphenidate, atomoxetine and in exceptional cases risperidone.
If we refer to behavioral treatments, one of the most widespread programs is Defiant Children, where parental intervention is contemplated through a series of very well structured and systematized guidelines aimed at the child acquiring a range of positive behaviors that help them achieve success at school and in their social relationships.
Another type of therapeutic approach to oppositional defiant disorder is Collaborative Problem Solving, where disruptive behaviors are understood as inflexible and explosive behaviors. In this case, the idea is that the child’s behavior is due to a delay in the development of specific cognitive skills, so the program focuses on the child learning to regulate emotions, developing tolerance for frustration and the ability to solve problems.
Anyway, it should be known that there are different therapeutic approaches to this disorder. Almost always, the psychologist’s first option is to opt for psychoeducational guidance; that is, training parents to learn the most appropriate way to relate to their child. Depending on the intensity of the pathology, psychotherapy can also be incorporated and you can even resort to pharmacological treatment (medications such as sertraline, fluoxetine, paroxetine, atomoxetine, risperidone and aripiprazole are usually used, depending on whether or not there are other associated disorders).
However, the results are not immediate and the success of the therapy will depend largely on therapeutic adherence; In other words, how much both the child or adolescent and their parents apply themselves to the therapy. It should always be kept in mind that the treatment of oppositional defiant disorder is not a therapy aimed exclusively at the child but at the entire family.
Secondly, one must be aware that each case is unique, which would require an individual analysis that allows for the implementation, not of a treatment of oppositional defiant disorder, but of a treatment of the person themselves and their specific family environment. However, if we speak in general terms we could refer to a series of guidelines or practical advices that could help you manage the child’s disruptive behaviors on a day-to-day basis.
How to treat a child with oppositional defiant disorder?
1. Pay attention to positive behaviors and reinforce them using praise, recognition or gratitude. On many occasions, parents focus on negative behaviors because they are the ones that cause discomfort and unpleasure, but it is very important to focus on everything positive that the child does. To understand the importance of this change in attitude, it is enough to put ourselves in their place for a second: what would we think and how would we ourselves act if we are never praised when we do something positive but, on the contrary, are constantly reproached for our mistakes?
2. Avoid negative behaviors. Sometimes yelling and anger act as reinforcers of behaviors that we would like to avoid. Therefore, whenever possible and it is not unforgivable behavior, it is better to ignore disruptive behavior. In this way they could become extinct on their own over time.
3. Anticipate problematic situations. If you know that there are particularly stressful moments in which the child or adolescent tends to respond negatively, the best option is to anticipate his response and propose another activity or another way to deal with this situation.
4. Explain what unacceptable behaviors are and why. This way the child will know exactly what is expected of him. Many parents make the mistake of punishing their children without ever telling them what they expected of them. Of course, this generates insecurity and resentment.
4. Give orders and set rules effectively and, more importantly, enforce them. On many occasions it is seen that a permissive educational style hides behind oppositional defiant disorder. Of course, the child immediately realizes this and takes control, becoming dominant and manipulative. Being consistent is a key factor in being able to eliminate disruptive behaviors.
5. Use punishment assertively. That is, instead of hitting or yelling, apply a punishment that helps the child learn an important lesson. Remember that violence generates more violence, so aggression (whether on a physical or mental level) is never the most appropriate solution.
6. Apply punishment immediately. Do not wait for the negative behavior to happen again, but rather stop it as it occurs. Also, remember that the punishment should not be proportional to the level of frustration you feel but should be appropriate to the actual transgression. Applying disproportionate punishments is as negative as not doing so.
7. Point out the specific consequences of his behavior. The child with oppositional defiant disorder needs clear rules but must also know what the consequences of his behavior are. Don’t get lost in musings about the future, simply make him notice the consequences in the here and now, from those on the material level to the damage from an emotional perspective.
References:
Rigau-Ratera, E. et. Al. (2006) Treatment of oppositional defiant disorder. Journal of Neurology ; 42 (2): 83-88.
APA (2002) DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders . Barcelona: Masson.
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