Developmental-behavioral pediatrician Barbara Howard
In the past decade pediatricians have become well experienced in managing patients with attention deficit hyperactivity disorder (ADHD), and consequently patient outcomes have been pretty good, noted developmental-behavioral pediatrician Barbara Howard at Hopkins Children’s annual Pediatrics for the Practitioner Update in September. But how have they fared in treating the related condition oppositional defiance syndrome, which Howard characterized as perhaps the most limiting factor in ADHD outcomes?
“Up to 60 percent of kids with oppositional behavior have ADHD, and they are often the ones who do not do so great,” Howard said. “So you want to pay attention to this.”
How is ADHD related to oppositional behaviors? Howard explained that children with ADHD have executive function problems like difficulty getting organized and judging how much time it will take to complete a task.
“Their clock runs differently,” Howard said. “They look at their homework and it looks too long for them, so they don’t even start.”
ADHD patients also have trouble with transitions or moving from one activity to another – especially if they’re sitting on the sofa playing a video game. Planning ahead is another problem, which explains why all too often the long-term school project gets done the night before it’s due. Impulsive talking, especially among girls, is another symptom of ADHD, as is impulsively taking things apart and leaving them strewn all over the house. To parents, the behaviors look like laziness.
“But it’s really not their fault,” Howard said. “These are symptoms of the problem that cause problems at home.”
Here, Howard explained, is where oppositional behavior comes in. Children with ADHD tend to make a lot of mistakes, and often the same mistakes, which annoys the parent to no end. So when the parent asks “Did you do that?” the immediate response is “no.”
“Think about it from the point of view of children who are chronically impulsive, who really can’t afford to constantly admit all the little things they do wrong because it’s too hard on their self esteem,” said Howard. “So they just deny it.”
But what the parents perceive is lying and willful defiance. Unresolved the interactions get worse. The parent repetitively criticizes the child for negative behaviors the child repetitively denies. What can parents do? What can pediatricians do?
Listing some strategies and tips, Howard recommended that pediatricians manage the ADHD first, which studies show tends to reduce the oppositional behavior. Then focus on the oppositional behavior by helping parents interact with their children in ways that allows them to save face, rather than cause them to act defensively. Do the parents empathize with the child? Give the child enough positive attention and time?
“Parents need to calm down their tendency to say something negative to the child,” Howard said. “Starting out with special time together is important, even with older kids.”
So how can parents get the child with oppositional behavior to do something? Pediatricians, Howard said, can teach parents how to give short, focused and more-effective commands: “’I want you to pick up that book now,’ is much different than saying, ‘Why don’t you clean up the living room when you get finished with all your stuff?’ Then give them praise for having done those steps.”
Positive reflections of the child, Howard added, may also be incorporated into the parent/child communication: “’You have many wonderful friends, but spending more time on Skype with your friends isn’t getting your homework done.’ The child is listening because you said something good about them.”
If the child doesn’t do what is asked, Howard said, he or she should go into timeout. And when they come out of timeout they still have to do the task. Watch the child closely but without a sense of suspicion that they’re always about to do something wrong, Howard added. Avoid corporal punishment and “nattering,” the tendency to always get on the child about something.
“Help the parents understand that the child who feels his parents see him as bad will live down to that reputation,” Howard said.
Discerning the meaning of the behavior for the parents is also important, Howard said. Ask the parents who the child takes after. That parent may be worried the child will turn out a certain way so he or she is more critical of the behavior. Also, ask the parents about the impact of the behavior on their lives, their family and marriage, which may open up other problems that need to be addressed.
Parents should try to get on the same page in working with the oppositional child, Howard stressed. When parents start to fight over how to manage it, the child tends to drift out of the room. Parents should be wary of sibling struggles, too.
“Sibling struggles can be the most painful part of ADHD,” Howard said, “because the kid with ADHD may be really jealous that the other child seems to have an easy time of it.”
Other issues to consider include sleep and side effects of sleep medicine, which may make the child more irritable. Earlier bedtimes and routines like the backpack by the door at night and clothes picked out in advance help in the morning, when disorganization can hit the fan.
Also, a developmental problem may be triggering oppositional behavior. Standard screening tools like Einstein or WRAT, Howard noted, can be used for 10 minute assessment of the child’s functioning. Howard also recommended Russell Barkley’s Your Defiant Child (Guilford Press, 1998), and Ross Greene’s The Explosive Child (Harper, 1998) for pediatricians and parents.
Noting that oppositional behavior can be predictive of later conduct disorders, Howard concluded, “Remember, oppositional behavior generally begins at home, and only later affects functioning at school. We don’t want to let that happen. We want to catch it in the early stages.”