oppositional defiant disorder (ODD ) is defined by a recurrent pattern of negative, defiant, disobedient and hostile targets figures authority While TOD has important clinical relevance, relatively few of our knowledge, possibly due to the false belief of considering this disorder as a variant or a manifestation of conduct disorder (CD).
TC t rastorno of conduct is a more serious disorder characterized by repetitive and persistent pattern of conduct that involves a violation of basic rights of others, social norms or laws.
for diagnosis requires the identification of conduct located at least
in three of the following groups:
1) aggression to people or animals;
2) aggressive behaviors that involve destruction of property;
3) fraud or theft;
4) serious violation of the rules. It is necessary that such conduct involving a social misfit, academic or occupational
In the general population, the prevalence of ODD is estimated approximately 2-16 %. About 75% of cases of attention deficit disorder and hyperactivity disorder (ADHD) are associated with other disorders. The most frequent comorbid ODD. This disorder increases the risk of having a TC during adolescence and antisocial personality in adulthood. The concurrence of the TC or DOT has been estimated between 15 and 60% for children with ADHD. Studies indicate that 40-60% of children / adolescents with ADHD have at some point in their lives a TOD. By contrast, if one looks at the problem from the opposite side, it appears that between 69 [6] and 80% of tweens with CT or TOD The criteria for ADHD. However, during adolescence forms 'pure' TC without ADHD are more prevalent.
Behavior problems are, in addition to learning difficulties, the most negative impact of ADHD. is therefore difficult to determine whether the behavior problems represent a comorbid or whether they are one of the main manifestations of ADHD. However, if the spotlight is fixed in the most severe behavioral problems, it is clear that these are distinct disorders, but may be related and mutually reinforcing. This does not contradict the existence of a large symptomatic overlap between the disorders. Regardless of the identification of TOD, most of children with ADHD have behavior problems with peers (classmates, friends ...) or with authority figures (parents, teachers, monitors ...).
Many of these problems stem from the difficulty that children with ADHD management or control of their emotions and activity. When compared the family environment of children with ADHD to children with ADHD more DOT or TC, has shown that in the pure forms of ADHD there is a much lesser degree psychopathology and family stress. Marital separations and family adversity were generally four times more often in cases of association ADHD with ODD or CT. Children with ADHD at 5 years living in family environments with high levels of adversity were five times more likely to become criminals.
An interesting follow-up study of 89 showed that hyperactive children into adulthood 39% of the sample had been any arrests, a figure significantly higher than the control group, which had been arrested only 20%. However, c hen analyzed the characteristics of patients with ADHD who had been arrested, only showed differences from the control group in the association of comorbidity with antisocial personality
Children with ODD are often identified from 2-3 years because of their disruptive behavior. Family disruption caused can be very important and creates serious problems in family life.
The diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR) for the TOD are:
A. A pattern of negativistic, hostile and defiant behavior lasting at least six months and which are present four or more of the following behaviors:
1. Gets angry and breaks into tantrums
2. Argues with adults
3. Adults actively defies or refuses to comply with its demands
4. Deliberately annoying others
5. He accuses others of their mistakes or misbehavior
6. Is susceptible or easily annoyed by others
7. Angry and resentful
8. Spiteful or vindictive
B. Clinically significant impairment in social, academic or occupational
C. The behaviors do not occur exclusively during the course of a psychotic disorder or a mood disorder
D. Not met disorder criteria and, if the subject is 18 years or more, nor those of antisocial personality disorder to understand the specific cognitive deficits that underlie ADHD place particular emphasis on executive functions
We have seen that executive functions are also involved in the development of disruptive behavior These include the 'working memory' , self-regulation, cognitive flexibility or ability to change and ability to solve problems through planning and organization. Working memory, occupying a nuclear role in executive functions, possibly because all are linked to this ability, is defined as the individual's ability to keep in mind events or information and operate with it s These deficits in executive functions affect the child's ability to respond adaptively to the environment or the adult guidelines.
The child with difficulties in working memory have difficulty discerning the consequences of a behavior based on past experience. For the same reason, can not anticipate the potential consequences of their actions. These cognitive difficulties the child can contribute to the emergence of a variety of behaviors that are considered oppositional.
BEHAVIORAL INTERVENTION
The first step before the onset of any behavioral intervention is tell whether a child's behavior is part of a normal variant or pathologic should consider taking into account the parameters of persistence, frequency and intensity. Not all children who misbehave are children with ODD .
Most disruptive behaviors occur regularly in children without psychopathology identifiable. In reality, wrongdoing as part of normal childhood behavior. In these cases the approach is simply an educational intervention was determined by the education of families. Of course, certain educational models may be more coherent and effective than others. But in any case, the ability to guide the child toward positive behavior, respectful and responsible is largely determined by the presence or absence of TOD.
conventional educational measures often fail in the DOT with executive dysfunction. The popular approach assumes that children who misbehave are consistent with the following assumptions: they are stubborn, manipulative, coercive, rude, controlling, challenging and seeking attention. Therefore, under this approach, the intervention should seek to show who is boss and what is the correct behavior, so that in this way the child to obey. Obviously, this model does not usually give too optimistic results, since the problem is not a child's ignorance about who the boss or what is good and bad behavior. Behavioral approach: Defiant Children
behavioral conceptualization of the idea that the misconduct is the result of poor parenting (inconsistent, non-contingent). For this reason, the child has learned that oppositional behavior is effective to manipulate the adults in order to capitulate to their wishes.
intervention programs from a behavioral perspective covering all contexts: family, school and the child itself. Most models behavioral intervention based on an analysis of behavior by so-called ABC approach (previous history, behavior, Consequences).
One of the most commonly used from the eighties is the behavioral-based program Defiant Children, adapted by Barkley and translated into Castilian in 1999. This has been one of the most common behavioral treatments used in the treatment of ODD. It provides for the involvement of parents through very structured guidelines systematized. An adaptation, is behavioral intervention program Orjales
Barkley program consists of eight steps which are to improve child's behavior, social relations and the general adaptation at home. This involves the application of certain principles. It tries to get the child to acquire a range of positive behaviors that help them succeed in school and in their social relations. The strategies used are designed to reduce the stubbornness, the behavior oppositional behaviors and increase collaboration. This program is based on the assumption that positive behaviors tend to increase if the child receives a reward or recognition for them, while the negative behaviors tend to die if they are ignored or receive negative consequences. Barkley introduces as a key collaborative effort of parents. The general concepts that underpin the program is summarized as follows:
- Consequences should be immediate
- not wait to repeat misconduct to respond
- Meet the positive behaviors to give immediate reinforcement The more immediate is the consequence of a behavior will more effectively control intervention helps
- The Consequences should be specific
- Both the prize and the punishment should be directed to a specific behavior, never to general aspects
- Punishment should be commensurate with the transgression not so much of impatience or frustration that parents have generated
- Consequences should be consistent Regardless of the setting, the consequence should be the same
- If a behavior is considered intolerable one day must also receive the same consideration other day
- Both father and mother must give the same answer
- Establish an incentive program before using punishment
- action plan prior to possible misconduct
- Anticipate, analyze and, if possible, prevent
- Recognize and accept that the interactions within the family are reciprocal. The parents' behavior is strongly influenced by the child's behavior and vice versa. Attributing blame is unproductive
The methods used to modify behavior are:
- Define a list of behaviors (the priority is compliance).
- A menu of rewards and punishments (ignore inappropriate behavior, time out).
- A token system.
The program requires eight steps to follow weekly intervals preferably are
- Learn to give your child positive attention
- Use the power of their attention to obey
- effectively orders
- Teach your child not to interrupt activities
- home Set a reward system
- Learn to punish bad behavior constructively
- Expand the use of time
- Learn to control your child in public places
is also important to monitor the effectiveness of parental interventions. For this purpose you can use a chart like the one shown in Fig. Cognitive approach: Collaborative Problem Solving (CPS) The CPS model has been developed by Greene
Most of the disruptive behaviors can be conceptualized as inflexible and / or explosive. Inflexible-explosive child has characteristics that are
- Difficulty controlling emotions
- Very low threshold for frustration
- Very low tolerance to frustration
- Low capacity for flexibility and adaptability
- tendency to think in a very radical black or white only
- Persistence of inflexibility and poor response to frustration
- despite a high level of motivation
- Episodes explosives for trivial reasons
- While other children may be more irritable when tired or hungry, inflexible-explosive children can be completely blocked in these circumstances
The PSC based on the idea that the child's behavior is due to a delay in the development of specific cognitive abilities (executive skills, skills in language processing, ability to regulate emotions, cognitive flexibility and social skills) or hard to implement these skills when necessary. Therefore, the behavioral problem must be viewed as a learning disorder focused on cognitive dysfunction. It is, therefore, closely linked to the internal language, emotional control, motivation and, ultimately, learning behavior.
Therefore, this approach focuses more on cognition in behavior, it is say, the approach to conduct disorder based on the premise that the child can do things correctly if you have the necessary skills. This model modifies the classical view according to which the child can do things the right way if he wants.
The fact the emphasis in these pathways allows the adult to understand that the explosive behavior is not intentional, goal-directed, manipulative or intended to get attention. Therefore, to identify the cognitive skills that need training.
is also based on the interrelationship between the child and adult. It is emphasized that the regulation of emotions, frustration tolerance and problem solving by the child does not develop independently, but depend, in large part on the way and the models used by adults to teach children. This model believes that the outcome of the behavior depends on the degree of compatibility between the characteristics of child and adult.
From this perspective, be considered oppositional behavior influenced by a conflict between parents and children, within which the characteristics of the interaction of one party (eg the child) are valued negatively by the second component interaction (the father), which contributes to maladaptive behaviors.
The compatibility between the characteristics of each component of the relationship has important implications in order to reduce oppositional behaviors. Therefore, the first objective is to resolve those points observed inconsistencies between the two parties. Given that a basic skills required to regulate the conduct, it is understandable that behavioral problems are observed in situations as diverse as:
- attention deficit disorder and hyperactivity
- nonverbal learning disorder
-
- autistic spectrum disorders
Tourette Syndrome Anxiety Disorders
An example to understand how some of the dysfunctions displayed modulates the behavior is reflected in the example of Charlie, age 8 (ADHD and ODD):
- Charlie: No, not yet completed the drawings.
- P: Turn off the TV and come eat. Next!
- C: I can not.
- Q: What does it mean I can not? The food is getting cold, come quickly!
- C: Hush, do not listen.
- Q: I've said this a million times ... Why not do what I say?, Why are you so angry?
- C: I do not know ...!!!
Regardless of what might happen from now on, we can stop Carlitos to understand what would explain if I had some basic problems which prevent it from, 'Look, Dad and Mom, I have this little problem.
constantly are asking me to go from A to B and I'm not very good at this. When you ask these changes, I start to feel frustrated. And when I start frustrated, I have trouble thinking clearly and I'm still so frustrated. Then you become crazy. I start doing and saying things that I would not do or say. Ye enfadáis and chastise me, and that makes me explode. Then, when everything is over, I begin to think clearly and I ask forgiveness. I know that you do not like, but it's fun for me either. "
When you see the frustration in a given situation and this can lead to explosive behavior, start a therapeutic approach. Once you know when the child is explosive, you have to find a cognitive explanation of what the functions do not have. explosive behavior occurs when the cognitive demands exceed the child's ability to respond adaptively . If you know what triggers this reaction, helps adults understand the child when an explosive acts, not intentional or manipulative. Thus, while cognitive skills are recognized, they have to train
addition to understanding the underlying deficit in disruptive behavior, the implementation of CPS requires placing each of the behaviors of the three categories listed below:
Behaviorbasket
-
- another
- Risk of breaking or damaging
- Attacking people's property (Examples: Paste , steal)
Assault
Behavior basket B
- behaviors without risk to himself or others, but they generate major problems in family dynamics (Examples: refusing to go with the family or an important event, excessive demands )
Behavior
basket C
- misconduct that do not generate risks for themselves and do not generate important problems in family dynamics (Examples: walking barefoot, swearing, not wanting to eat lentils, no follow the standard of 'civility', finger foods, leaving the table)
educational purposes bearing the title of 'basket' for each of the three categories.
The performance of the parents must be determined by the rating to be established for each improper conduct. If the conduct is for the drum A, the priority is to curb the behavior, otherwise it could lead to unacceptable consequences. Therefore, in this situation is not discussed, not argued, no yelling, just repressed adult behavior and imposes its authority. It is certainly possible that the child does not improve their basic skills, but has avoided damage.
behaviors basket
C are the most frequent and, therefore, the most common cause of domestic disputes. The popular belief is that if parents do not intervene, they lose their authority and the child each time is worse educated, spoiled and rebellious. Certainly parents will lose their authority if they try to suppress the behavior and fail. Conversely, if parents get curb the behavior, they may trigger an extremely stressful for families and children, without necessarily have improved the cognitive skills underlying the problem. It's hardly bearable in a family setting a daily struggle to get the child to permanently control situations that are very difficult because of their low ability to regulate behavior (flexibility, impulsivity, low frustration tolerance, etc.).. Appropriate in situations C is' so far no action. " Not prohibit, without thereby accepting that such behavior is appropriate. Thus, the authority or parental influence is not affected, since there is no violation of the rules.
basket B behaviors are most important to influence the improvement of basic skills. From these situations it is intended that the child is able to modulate their behavior based on reflection, flexibility and restraint. But This will require certain steps to achieve these objectives.
The initial steps are to show empathy, define the problem and invite the child to find a solution acceptable to him and the adult, in which both must compromise. Empathy makes it easier for children and adults remain calm. The definition of the problem ensures that the concerns of the child is on the table (if you do not know what the concern, we find out). Sometimes it is necessary as an additional reassurance to stay calm. It allows the child to detect that we are doing something 'with it' rather than 'a him. " Let's see how we can solve this problem. It must give the child the first opportunity to generate solutions. Solutions are not really bad, just not realistic solutions mutually satisfactory or not. Therefore, it must reach an ingenious solution, ie any solution in which parents and child agree, besides being a realistic and mutually satisfactory alternative. In reality, what matters is not who 'wins', but the process itself. Resume
whole process. Structure of the Collaborative Problem Solving.
Basic principle :
behavior is a cognitive function. Behavior problems are due to delayed development of the necessary functions to be flexible and tolerate frustration
All behavior can
Basket A: adult imposition
Basket B: for jointly solve the problem states:
- Empathy
- Define the problem
- Invitation
basket C: ignore certain behaviors
The CPS aims to:
- to help adults identify and use three basic strategies to improve the skills required by the child to "learn" the correct behavior.
- Helping adults to recognize the impact of each of the three strategies in their interactions with the child.
- Help the child and adult to become experts in the CPS as a way to resolve disagreements and reduce potential conflict situations, so as to improve the compatibility between them.
This approach is a multifaceted psychosocial model of treatment which aims to teach the cognitive deficit with these children, which is part of the idea that many TOD have their origin in a
executive dysfunction. The main objective of this program is to assist adults to work effectively with the child to solve those problems or situations that trigger the explosive behavior and to provide a space which, through empathy, negotiation and language, is conducive to joint resolution of the situation problematic.
Finally, we must take into account, as stated by Greene [19], that 'the major premise of this approach is to consider that the child chooses to be explosive or go against the rules
-in the same way a child does not choose to have difficulties in literacy, but has a delay on these skills that are crucial to be flexible and tolerating frustration. "
DRUG INTERVENTION
- selective inhibitors serotonin reuptake (sertraline, fluoxetine, paroxetine). Indicated when there is an important component of anxiety or obsessive behavior.
- Stimulants, selective inhibitors of dopamine reuptake (methylphenidate). Indicated when comorbidity with ADHD and behavioral problems related to impulsivity, self-control or difficulty processing information from the environment. You must use methylphenidate sustained action to obviate the rebound effect by itself can worsen the behavior in the family. Must also do weekend breaks or holidays therapeutic.
- reuptake inhibitors of noradrenaline (atomoxetine). also indicated for ADHD, is indicated when there is an anxiety component.
- atypical antipsychotics (risperidone, aripiprazole) . Only the first is authorized for use in children and is an indication in sheet behavior problems in children with autism spectrum disorder. Can be used in cases of aggressive behavior of a serious nature. Moreover, risperidone is an excellent drug for the control of tics.
The optimal approach will be that a reasonable and sensible to contribute, either alone or together, behavioral techniques and the prescription of the drug or drugs suitable.
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