Behavioral Disorders


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Q: What is oppositional defiant disorder? Shouldn’t parents just set boundaries and discipline their children more?

A: The answer is “yes.” You should set boundaries and discipline children as much as they need disciplining. Oppositional Defiant Disorder is not like most disorders psychiatrists/therapists deal with in that most have a genetic/chemical cause or underpinning. ODD describes a set of behaviors that can be associated with any disorder or stand-alone. Essentially the name describes the disorder. Behaviors include arguing with adults, losing one’s temper, refusing to follow rules, deliberately annoying others, blaming others, being irritable, being spiteful, and having general anger and resentment. These behaviors have to be beyond the usual (we all have these behaviors at times) and be enough to significantly interfere with adaptation to home, school and social lives.

Every child can be oppositional and defiant. Routine limit-setting should work for the average child. If behaviors are extreme and extensive, then a diagnosing of ODD can be made. Nearly always if the behaviors are this bad, there is another disorder that is primary. I will outline the most common primary disorders and then talk about treatment.

Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder is the most common primary disorder associated with ODD. About 10 percent of children have ADHD. ADHD includes behaviors of not listening well, dragging one’s feet, forgetting to do things, not following through and not completing tasks. Impulsivity is also present and that leads to arguing, disagreeing, being spiteful and resentful. As you can see, these behaviors look very similar. The treatment of ADHD is medication, which improves these behaviors considerably.

Bipolar Disorder of Childhood
Mood disorder and “Bipolar Disorder of Childhood” include inability to regulate emotions and anger and that leads to defiance, temper tantrums, irritability, deliberately annoying others, moodiness and mood swings. Medications are not very helpful in these disorders — perhaps because we just do not have the right medications yet. Psychotherapy also does not lead to quick, clear improvements most of the time. The combination of both should lead to some improvement.

Asperger’s
Disorders such as Asperger’s and language-processing disorders lead to very similar behaviors due to inability to understand or process social expectations. Consequently, these children can be irritable, oppositional, defiant, rude, inappropriate, have frequent temper meltdowns and don’t follow expectations. Again, these are very similar behaviors.

Anxiety and Depressive Disorders
Other disorders such as anxiety and depressive disorders can have similar behaviors, but as a rule not as extensive or annoying. Stress in the family and at school can also lead to transient ODD behaviors.

Treatment of ODD and similar behaviors include addressing the primary disorder. Regardless of the cause, the ODD behaviors should be addressed and not excused by the primary disorder. Rules of every household should be clear. That means routines are in place (bedtimes, not hitting, homework, respect toward others, etc.), and consequences should be routine and quick also. With ODD, the expectations have to be clearly said, repeated, even written down at times. The parent has to follow through with supervision, reminders and consequences on the spot. Repetition of this set of parental behaviors needs to be done as often as necessary.

Discussion and bargaining are pretty much a waste of time. It is important that parents practice what they preach. They should listen to and respond to their children, appropriately express anger toward their children and spouses when necessary, demonstrate respect and disagree respectfully. If the parents do not set the example, it is unlikely the child will change.

The most common mistake is not following through with consequences. It is hard to think of appropriate consequences for many situations and hard to follow through because it takes time, patience, controlling one’s own anger and letting go of one’s own plans for the day. Arguing with the child or trying to reason with him beyond the simple explanation from the parent and brief defense from the child should be avoided.

Consequences should be thought out ahead of time and constantly re-thought to stay ahead of the child. Natural consequences (i.e. did not study, fail the test) should be respected. Consequences that do not require policing (i.e. withholding money or time) are the easiest to enforce. Other consequences will require enforcement (i.e. timeouts, no video/computer time, no TV, etc.) and these need to be as consistent as possible.

These are general principles. Specifics need to be worked out individually for each child. If problems persist, see a therapist. They can be a major help with behavioral management.

Gerald Taylor, M.D., is a psychiatrist with Moses Cone Behavioral Health System Psychiatric Associates. Please submit your questions to “Is My Kid OK?” by e-mailing sherri.mcmillen@mosescone.com.
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