Introduction
All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.
Dr. Allison Hall
Case summary
A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.
Discussion
Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.
There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.
When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role
In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.
These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.
It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.
How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.