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.