Oppositional children present with problems such as frequent temper outbursts, argumentativeness, noncompliance, and negativism. The child who terrorizes your waiting room, dismantles your exam room, or refuses to cooperate with physical examinations may be oppositional. The child who does what he or she wants, when he or she wants, and without regard for what his or her parents or other authority figures want, may be oppositional.
The prevalence in the United States of true oppositional defiant disorder, as defined by the Diagnostic and Statistical Marmai for Mental Disorders , Third Edition, Revised (DSM-NI-R), is approximately 11% of all children, with boys slightly more commonly described in this way than girls. However, if the component behaviors that make up the definition of "oppositional" are included, independent of the full cluster required for the formal diagnosis of oppositional defiant disorder, then approximately 33% of boys and 20% of girls will be identified as oppositional at any one time.' Thus, the pediatrician probably encounters a child who presents with oppositional behaviors virtually every day. "Although no consistent etiology has been demonstrated for children with oppositional behaviors. . . it does seem clear that certain discipline patterns by parents are likely to lead to oppositional behavior, including discipline that is lax, that is unduly harsh or restrictive, or that is inconsistent."1
The major issue in assessing oppositional behavior is to determine whether the problem behaviors are significantly greater than one would expect for an average child at that age, sex, and level of development. Assessment can be used to help the practitioner in identifying children with oppositional behaviors as well as children who can be formally diagnosed as oppositional defiant disorder. Because the pediatrie well-child visit is not necessarily conducive to interviewing parents at any length,2 the primary care physician can organize well-child visits in such a way that children are routinely screened for behavior problems. While this procedure is not without false positives,5 it does generate information for the provider in a systematic way that can then be weighed and a decision can be made about whether to pursue it. This can probably best be done by incorporating routine screenings into well-child visits, using parent rating scales.4
There are several parent rating scales that are easy to administer, score, and interpret. The first of these, the Eyberg Child Behavior Inventory (ECBI), consists of 36 questions and is normed for children ages 2 to 1 2 (Figure).5 If mailed to all parents prior to their child's 2-year well-child visit, for example, the parent can fill out the answers at home and bring the completed ECBl to the office visit. Otherwise, the ECBI can usually be completed in the time that a parent is in the waiting room or in the exam room waiting to be seen.
By skimming through the answers that the parent chooses and comparing these answers with the answers normally received, the pediatrician can make a judgment as to whether further investigation or questioning is in order. Because the ECBI is a standardized and normed test, the number of problem behaviors (problems) and the severity of the behaviors (intensity) can be added and these individual scores can be compared with the norms.
Perhaps the most widely used parent rating scale is the Parent Symptom Questionnaire (PSQ) by Conners.6 The PSQ has 48 questions that are answered "not at all," "just a little," "pretty much," and "very much." There are norms available for both boys and girls, from 3 to 17 years of age. The PSQ has been factor analyzed to yield scores in the following major groupings: conduct problems, learning disability, psychosomatic problems, impulsivity-hyperactivity, and anxiety.
The Achenbach Child Behavior Checklist (CBCL) is a much more comprehensive assessment device that takes longer to fill out and longer to score, but provides much more information than the brief screening instruments. The CBCL has 1 12 questions and is normed for children 2 to 16 years of age.7 There are separate forms for 2 to 3 year olds, 4 to 5 year olds, and 6 to 16 year olds. The scoring forms are normed for boys and girls. Forms are available for parents of children ages 2 to 16, for teachers of children ages 6 to 16, and for children ages 11 to 16. Computerized scoring is available for the CBCL.
Children with oppositional problems vary in terms of the severity of their presenting symptoms. The primary-care provider who is adequately trained in this area can effectively manage many of the children who present with mild to moderate oppositional behaviors. Children who present with a severe oppositional disorder, often including aggressive behaviors and physical acting out, usually require the expertise of a pediatrie psychologist or psychiatrist who is experienced in dealing with this type of disorder. In uncomplicated cases of oppositional defiant disorder (eg, where there is no evidence of attention-deficit hyperactivity disorder or conduct disorder), pharmacotherapy has not been found to be effective.1 The primary provider, however, can try to teach the parents how to obtain general compliance prior to any decision to refer. If the parents are able to obtain general compliance, then referral to a subspecialist may not be necessary.
It is important to intervene as early as possible with children who present with oppositional problems. Many researchers in this area believe that oppositional behavior may be a "cornerstone behavior" in the development of later, more severe behavior disorders. Left untreated, oppositional problems might lead to problems of much greater severity. Fortunately, recent evidence indicates that early intervention may prevent many uf these more severe problems from developing.
Teaching parents improved behavior management techniques is a mainstay of behavior therapy for oppositional children. With young children, parent training often focuses on differential attention for compliance and other desired behaviors, ignoring problem behaviors when possible, and time-out for misbehaviors such as noncompliance, tantrums, and aggressive behaviors.0'10 Changing parent behaviors that serve as antecedents, such as vague or nagging ways that parents give instructions to their children, and providing structured learning opportunities for techniques of differential attention yield a curriculum for clinic-based assessment and treatment.
Changing Parent Behaviors
With a great many parents who are motivated to change, providing them with behavior management strategies is sufficient.11 The parents' task is often simplified if the pediatrician makes recommendations when the child is 18 months old rather than waiting until the parents repon having problems with a 2- or 3-year-old child. By addressing the topic of discipline with parents during the 6-month well-child visit, the provider can give the parents suggestions before they start a haphazard approach to discipline.12 The author's own research seems to indicate that parents are more likely to incorporate suggestions made by their pediatrician if the suggestions are made early. Also, because many parents may have difficulty remembering everything that their pediatrician tells them, written handouts, or summaries of the recommendations should be given to the parents in conjunction with verbal discussions.9,13 That way, parents can concentrate on what is being said without taking notes because they know that the pediatrician will give them summaries to take home and read at their leisure or when needed.
Figure. The Eyberg Child Behavior Inventory.
Parent Coping Skills
Some parents tend to respond immediately and emotionally to their child's transgressions. Rather than plan their approach or think ahead, they react immediately, usually in a negative fashion. Barrish and Barrish have developed a program for parents that teaches them strategies for keeping their tempers.14 The basic approach of the program (Stop, Think, Act) can help parents react more reasonably to what their children do; the strategies encourage parents to develop "helpful thoughts" rather than "hurtful thoughts." Most of the time, a parent can have either type of thoughts; the helpful thoughts are more likely to result in the parents taking a reasonable approach to their child's behavior.
Vami and Christophersen suggest advising parents in groups rather than individually.15 Such groups have the advantage that each parent gets much more time with their provider, for the same fee, with a corresponding increase in the amount of time devoted to discussion and questions and answers. Given the added amount of time that the classes provide for interaction between the provider and the parents, topics such as parent coping skills, child development, and discipline can he discussed at length with parents.
The Roots of Discipline
Behavioral researchers have long known that discipline never teaches a child what to do - it only teaches a child what not to do. Teaching a child what to do, prior to instituting any disciplinary procedures, is the most effective approach to modifying a child's behavior. There are several skills that, when taught to children early, will reduce the need for discipline later and make discipline, when used, more effective. The two major skills are independent play and self-quieting.13,16
Independent play skills refer to a child's ability to entertain him- or herself, to enjoy playing alone. If parents are advised to begin to teach their child "independent play" skills at the 6-month visit, the parents can begin doing so then, when it is still relatively easy to do so before discipline even becomes an issue and when the parents can see a difference in their child in a brief time period. Independent play skills are best encouraged by providing a lot of brief, nonverbal, physical contact to an infant or child who is engaged in independent play. Over time, the combination of the enjoyment of the independent play and the physical contact from the parent is usually enough to encourage more independent play on the child's part. Researchers have shown that discipline is more effective when a child is encouraged to engage in independent play in addition to the use of a punishment procedure.17
Although there are a wide variety of disciplinary techniques that are available to today's parents, probably none is better researched or better understood than "time-out." It is important to note that the use of the term time-out is actually an abbreviation. When the concept was introduced into the child development literature, it was called "time-out from positive reinforcement." Initially, studies on the effectiveness of time-out all started by greatly increasing the amount of attention that children received for their appropriate behaviors, prior to introducing the use of time-out. In one study, "enhanced time-in" was compared to "impoverished time-in," demonstrating that time-out was more effective when the child was provided with "enhanced time-in."18 For a more detailed description of time-in, see the accompanying piece on page 270, "Tune-In."
Thus, although many researchers and clinicians discuss the use of time-out as though it is somehow related to sitting in a chair or to being isolated, the situation that the child is removed from, the time-in, is at least as important as the time-out. Similarly, the use of time-out initially may produce a predictable response from a child in that some children will become much more oppositional when their parents begin using time-out as a disciplinary procedure.19 This initial increase in oppositions! behavior, while predictable, usually subsides soon.
In the authors clinical experience, teaching parents to begin with very brief time-outs, just 2 to 3 seconds of quiet, calm behavior, has made it much easier for parents to implement time-out as a disciplinary procedure. After the child has learned to selfquiet with these brief time-outs, the parents are instructed to gradually lengthen the period of quiet calm before the time-out is over. The maximum length of a time-out should be 1 minute per year of life up to the age of 5. The use of time-outs longer than 5 minutes for any age is not recommended.1 } Parents can begin using time-in with their child by 3 to 5 months of age. They can begin using time-out with their children at about 8 to 10 months of age.
Teaching Alternative Skills
As mentioned above, all discipline does is teach children what not to do. Parents must, therefore, be encouraged to teach their children a wide variety of skills. Parents should be forewarned that it takes time and many, many repetitions in order to teach children new skills. In feet, repetition is probably the most important variable in training children. The more repetitions, the faster the child learns. Too often, parents become frustrated when their child can't learn within a time frame capriciously selected by the parents.
Having Good times With Children
Far too little emphasis has been devoted in the child development literature to the importance of parents spending enjoyable, non-manding time with their children. Non-manding refers to the absence of demands and requirements. Examples of such situations include watching television together or cuddling on the sofa - basically, just relaxing together. There are many families whose schedules are so hectic that the parents depend on discipline to keep their children "in line" without ever really developing a tender, caring relationship with them.
Early intervention for children's oppositional behaviors is likely to be more effective than later treatment. The term oppositional includes a variety of noncompliant and aggressive behaviors that can be assessed with clinical interviews, rating scales, direct observation, and self-report measures.
Treatment of children's oppositional behaviors is best approached from a parent training perspective. Parent training approaches have produced significant improvements in children's behavior, although far more research has been devoted to discipline than to identifying the more salient features of time-in. Recent advances in assessment and treatment are notable, but continued efforts are needed to determine the optimal treatments that produce the best social and psychological outcomes for children and adolescents.
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16. Christophersen ER. Beyond Discipline Parenting That Lasts a Lifetime. Kansas City, Mo Wesiport Publishers; 1990.
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Figure. The Eyberg Child Behavior Inventory.