Oppositional & Defiant Behavior in Children & Teens

Overview of Oppositional & Defiant Behavior in Children & Teens: One the most frustrating and heartbreaking experiences for parents is trying to manage the behavior of a child who misbehaves frequently. Sometimes, a child seems incapable or completely unwilling to follow rules, cooperate with adults, or accept any sort of discipline or structure. Other times, a child may go for long periods without an episode of oppositional behavior, and then, either due to a small trigger or for no apparent reason, break significant rules, use abusive language with adults, or in some way act out.

Often, oppositional children show remorse at least sometimes, and may make promises, ask forgiveness, and seem to try to do better.  Some such promises may be manipulative, and some may be sincere. Even so, they seem to revert to their difficult ways again and again. And, often, oppositional children do not show remorse or promise to do better. Some children seem to have no regard for the consequences of their behavior for themselves or for other people. They may be emotionally numb and quite unhappy. Defiant behaviors are potentially devastating in school, and can be very frustrating at home. Sometimes, infractions of the law can even occur. Left unaddressed, oppositional behavior can escalate into adulthood, where such actions can lead to lasting consequences socially, legally, occupationally, and psychologically.

Oppositional children often have a history of abuse or neglect. Sometimes, a chemical issue may be present; women who abuse drugs or alcohol during pregnancy increase the odds of oppositional behavior in their children. Oppositional behavior may develop when parents do not succeed in teaching boundaries. A trauma can be a cause. However, in some cases there is no identifiable root, and this may make treatment more difficult. Therapists may use behavior modification techniques, such as rewards and consequences, or may employ play therapy, family therapy, or other techniques depending on their philosophy and the particular child.

It is important to remember that at certain ages, children may be quite rebellious. During adolescence there may be frequent bouts of anger and misbehavior; toddlers are also fond of exerting their individuality by being contrary and refusing to follow rules in bouts and phases. These behaviors are not diagnosable, although they may be frustrating and certainly require some parental skill with boundaries, compassion, patience, discipline, and communication skills.

Diagnostic and Statistical Manual of Mental Disorders (DSM): Oppositional Defiant Disorder can be diagnosed when oppositional behaviors form a pattern over at least six months. Diagnostic criteria for 313.81 Oppositional Defiant Disorder includes:

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

(1) often loses temper 
(2) often argues with adults 
(3) often actively defies or refuses to comply with adults' requests or rules 
(4) often deliberately annoys people 
(5) often blames others for his or her mistakes or misbehavior 
(6) is often touchy or easily annoyed by others 
(7) is often angry and resentful 
(8) is often spiteful or vindictive

NOTE: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

 
D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

The more serious diagnosis of conduct disorder describes an extreme of the disruptive behavior spectrum, in which aggression and cruelty, property destruction, and deceitfulness are prominent.

Diagnostic criteria for 312.8 Conduct Disorder  (cautionary statement)

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

 
Aggression to people and animals

(1) often bullies, threatens, or intimidates others 
(2) often initiates physical fights 
(3) has used a weapon that can cause serious physical harm to others (e.g., abat, brick, broken bottle, knife, gun) 
(4) has been physically cruel to people 
(5) has been physically cruel to animals 
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery) 
(7) has forced someone into sexual activity

Destruction of property

 
(8) has deliberately engaged in fire setting with the intention of causing serious damage 
(9) has deliberately destroyed others' property (other than by fire setting)

Deceitfulness or theft

 
(10) has broken into someone else's house, building, or car 
(11) often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others) 
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

 
Serious violations of rules

 
(13) often stays out at night despite parental prohibitions, beginning before age 13 years 
(14) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) 
(15) is often truant from school, beginning before age 13 year

 
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

 
C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder. 

Case Examples of Oppositional & Defiant Behavior in Children & Teens:

Gerald, 12, is brought to therapy by a foster parent. He is sweet and cooperative much of the time, but just as often he talks back rudely, purposefully breaks rules, sneaks out of the house, speaks angrily to everyone around him, and never takes responsibility for his chores, his words, or his actions generally. His foster mother reports Gerald was neglected by his mother and has been in several foster homes. His current foster family would like to adopt him, but they are worried they will not be able to manage his behavior, which seems to be getting worse. The therapist begins by engaging in play with Gerald – art projects, games, and toy army battles. As the therapist develops a relationship with Gerald, the foster parents are brought into some of the sessions. Gerald is encouraged to write, draw and talk about his experiences in other foster homes, and he is encouraged to communicate these experiences through various means of performance – puppet shows, a play involving everyone in the room, a story with the army men. Soon, Gerald begins to show real trust for his foster parents, his anger becomes more manageable, and his behavior, while far from perfect, improves enough to make adoption possible.

Alice, 17, is staying out beyond curfew, cutting school, eating junk food all day, drinking alcohol on weekends, and cursing at her parents if they try to talk to her about any of this. This has gone on all senior year – 8 months so far. The parents are at wit’s end, and seek therapy, but Alice won’t go. The therapist talks to the parents about their options, all of which seem terrible; do they emancipate her, or continue trying to help her? The therapist explores the couple’s relationship, history, and parenting style, and continues to work with the parents, helping them to manage their own stress and address some long standing intimacy issues. The parents are amazed to report after a couple of months that Alice is doing better, staying home more. She agrees to enter therapy, and this begins a conversation in which her parents become aware of the many ways they have sent mixed messages to Alice, and Alice becomes aware of the pain she is causing in her family. Her behaviors begin to subside.

Therapy for Oppositional & Defiant Behavior in Children & Teens: There is a wide range of Psychotherapy Treatment Models or types of therapy used in the treatment of oppositional and defiant behavior in children & teens. Most of these approaches fall into three historic camps of psychology: Psychoanalytic / Psychodynamic approaches; Behaviorism and; Humanism. Regardless of the type of therapy, there are some generally agreed upon elements of healthy therapy which are universal to all forms of psychotherapy. Before beginning therapy for oppositional defiant disorder or any other issue, it is helpful to familiarize oneself with these elements.

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