Four year old Sarah throws temper tantrums, won't go to bed, refuses to take a bath, and is described by her parents as "hell on wheels." Peter, age seven, often won't go to school, refuses to take his dishes into the kitchen or perform other simple household chores, and screams when he doesn't get his way. Thirteen year old David refuses to listen to his parents. He stays up past his bed time, argues with his parents about everything, and stays out past his curfew. His parents are seriously considering bringing a PINS petition against him; they just don't know what to do.

Do any of these children sound familiar? If so, you may be thinking of an oppositional and defiant child. We know from extensive research that non-compliant behaviors in children increase in severity over time. While 25% of children with oppositional and defiant disorder (ODD) no longer have that disorder three years later, and over 50% will continue to have ODD three years later, and 25% will progress in severity and meet the criteria for Conduct Disorder, which involves more severe oppositional behaviors and “juvenile delinquent” type behaviors.

What are some of the other typical none compliant behaviors seen in children with ODD? Behavior such as:

are all common behaviors exhibited by children with ODD.

It is very important to distinguish ODD from similar behaviors that are seen among children with attachment difficulties, attachment disorder, and reactive attachment disorder (RAD). This distinction is critical since effective methods of treatment for ODD are ineffective with children exhibiting similar behaviors who have disorders of attachment. So, what are some of the major distinctions between how ODD behavior develops and similar behaviors exhibited by attachment disordered children?

Most frequently, a combination of factors contributes to the development of ODD. All children want attention. Sometimes, through simple reinforcement, children learn to misbehave as a way of getting their parent's attention. As this behavior continues, the parents may even begin to ignore positive behavior, taking the approach of, "let sleeping dogs lie."

When the child desires attention, the child misbehaves and the parent attends to the child. A cycle begins in which the child's oppositional behavior becomes self-reinforcing as a method of getting the parent's attention. Peter’s parent’s asked me, “Why does he act the way he does? He spends more time avoiding doing what we ask him to do than it would take to do it!” I explained that every minute that Peter is able to argue and avoid doing an undesirable task is an additional minute that he continues to do what he enjoys, such as watching TV or not going to bed. Avoiding an undesirable activity is reinforcing.

On the other hand, children with attachment disorders exhibit oppositional behaviors because of very strong needs to be in control. This strong need to be in control is based on a fundamental lack of trust. Usually, because of significant difficulties during the first year or two of life, these children do not develop a sense of basic trust. As a result, these children experience requests by their parents as demands which must be fought. The result of the child’s fundamental lack of trust, is oppositional behavior and an unwilling to follow directives.

Normal attachment develops during the child's first two years of life. Problems with the mother-child relationship during that time, or breaks in the consistent caregiver-child relationship, prevent attachment from developing normally. Emotional vulnerability can be affected by a variety of factors including: genetic factors, pre-natal development including maternal drinking and drug abuse, pre-natal nutrition, and stress, fetal alcohol syndrome and fetal alcohol effect, temperament, birth parent history of mental illness (schizophrenia, manic depressive illness, etc.)

So, how can we tell the difference between a child who "looks" attached, and a child who really is making a healthy, secure attach­ment? This question becomes important for adoptive families, because some adopted children will form an almost immediate dependency bond to their adoptive parents. To mistake this as secure and healthy attachment can lead to many problems down the road. Just because a child calls someone ''mom'' or "dad," snuggles, cuddles, and says ''I love you," does not mean that the child is attached, or attaching. Saying, "I love you", and knowing what that really feels like, can be two different things.

Attachment is a process. It takes time. The key to its formation is trust, and trust becomes secure only after repeated testing. Normal attachment takes a couple of years of cycling through mutually positive interactions. The child learns that the child is loved, loveable, and can love in return. The parent's give love, and learn that the child loves them. The child learns to trust that his needs will be met in a consistent and nurturing manner, and that the child "belongs" to his family, and they to him. Positive interaction, trust, claiming, and reciprocity (the mutual meeting of needs, give and take), these must be consistently present for an extended period of time, for healthy, secure attachment to take place. It is through these elements, that a child learns how to love and how to accept love.

WHAT WORKS

Children with ODD are most effectively treated with a program that begins with paying attention to and reinforcing the desired behaviors. One begins by rewarding compliant behavior rather than punishing oppositional behavior. I teach parents specific methods and techniques to focus on and reward compliant behaviors in a consistent manner. One method is to have each parent spend ten or fifteen minutes each day playing with the child. The parent is instructed to avoid giving commands and to make positive comments to the child about the child's play.

Another method is to ask the child to play quietly while the parent reads a magazine or makes a phone call. Every few minutes, the parent is to praise the child for playing so quietly and allowing the parent to read or make the call. Gradually the time between verbal reinforcement is extended. The second step in this process is to begin using a number of methods to eliminate the undesirable behaviors. Time out, points, charts, and other methods are taught to the parents.

These methods are highly effective with ODD children. However, the same methods are ineffective with children with attachment disorders. So, how does one address oppositional behaviors exhibited by attachment disordered children? The most important concept is “Units of Concern.” This concept involves creating situations in which all of the difficulty or concern about a problem rests on the child's shoulders rather than on the parent's shoulders. Rather than allowing the child to create a conflict between the child and the parent, you structure the situation and consequences so that the conflict and consequences affect only the child. For example, when a parent gets into an argument with a child about getting washed up and coming to dinner it is usually the parent who is most concerned about getting the child into the dining room. In this example the parent has all of the units of concern while the child has none.

One method for turning this around is to let the child know that dinner will be served in ten minutes and that the child can feel free to join the family as soon as the child gets washed up. There are no reminders or any further discussion. The child can take as long as the child wants to get ready and come to dinner. However, if by the time the child gets to dinner, supper is over, the parent’s response to the child’s question, “what's for dinner?” can be a simple, "breakfast." In this example, the natural consequence of the child’s disobeying the parent is a missed meal. It is the child’s dawdling that created the outcome. The parent is not nagging, yelling, reminding, or punishing the child. In other words, the parent is taught to find creative ways to allow natural consequences to help shape the child's behavior and learn to trust the parent.

Common methods of discipline such as reward, punishment, and star charts do not work with attachment disordered children. A completely different parenting approach and different methods must be used with these children. A combination of creating a highly structured and controlled environment, the velvet lined steel box, along with a high degree of love and nurturance is required to help of these children learn to trust. Once trust has been established, much of the oppositional behavior disappears.