NCP Oppositional Defiant Disorder

DSM-IV

313.81 Oppositional defiant disorder

312.9 Disruptive behavior disorder NOS

A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, in which the child loses temper, argues with adults, often actively defies or refuses adult requests or rules, blames others, deliberately does annoying things, and swears or uses obscene language. This behavior creates significant impairment in academic/social functioning but does not meet the criteria for conduct disorder. (Disruptive behavior disorder NOS reflects clinical features that constitute the subthreshold for both oppositional defiant and conduct disorders.)

ETIOLOGICAL THEORIES

Psychodynamics

The oppositional youth is fixed in the separation-individuation stage of development. The youth insists on autonomy by negative adaptive maneuvers in which he or she continually provokes adults or peers. As the youth develops internal controls, he or she will eventually grow out of these behaviors.

Genetic/Biological

Similar to the predisposition for conduct disorder, heredity contributes to individual temperament, frustration, tolerance, and the tendency to seek risks or disobey authority. The disorder may be gender-linked, as the incidence is higher in boys than in girls.

Family Dynamics

Familial and cultural norms may prohibit the degree of individual differentiation among the family members. Attempts to maintain conformity are met by negativism, disobedience, and quarrelsome defiance. Parenting skills are ineffective and/or inconsistent with reactive and emotionally charged interchanges between parent and child. Some parents interpret average or increased levels of developmental oppositionalism as hostility and as the child’s deliberate effort to be in control. If power and control are issues for parents, or if they exercise authority for their own needs, a power struggle can be established between the parents and the child that sets the stage for the development of oppositional defiant disorder.

A relationship between life events and the development of anxiety disorders has been identified. This theory suggests that disruptive behavior is learned as a means for a child to gain adult attention. Anxiety generated by a dysfunctional family system, marital problems, etc., could also contribute to symptoms of this disorder. Parents become frustrated with the child’s poor response to limit-setting. Parenting intervention become oversensitive or the reverse, with no external structure provided.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Difficulty playing or engaging in leisure activities quietly

Ego Integrity

Feelings of rejection, powerlessness, fear of abandonment

Blames others for what happens to self; easily annoyed by others

Passive-dependent or demanding attitude of entitlement

Family may report emotional lability

Food/Fluids

Dawdling at mealtime

Oppositional battles over food choices and at mealtimes

Hygiene

Rebellious display of defiance in personal appearance, adherence to hygiene, and personal habits

Neurosensory

May be depressed, angry, or react with ambivalence or hostility

Dawdling, passive resistance to time schedules, missing school bus, etc.

Social Interactions

Displays impaired social and academic functioning

Shows provocative display of defiance of adult authority figures

Deliberately engages in annoying behaviors; ignores verbal instructions/requests

Often bullies or bosses others (peers, siblings)

Aggressively interrupts play activity of others; breaking toys, making up own rules for games, etc.

May/may not participate in social activities

Interpersonal relationships impaired (e.g., loses temper, argues, refuses to comply with requests or rules, is spiteful or vindictive, projects blame for own mistakes or misbehavior, interrupts or intrudes on others)

Teaching/Learning

Onset usually before age 8, and not later than early adolescence

Family history of alcohol abuse

DIAGNOSTIC STUDIES

(Studies are done to rule out other conditions that may contribute to presenting problems.)

Thyroid Studies: May reveal hyperthyroid/hypothyroid conditions contributing to problems

Neurological Testing (e.g., EEG, CT Scan): Determines presence of organic brain disorders

Psychological Testing (as indicated): Rules out anxiety disorders; identifies gifted, borderline-retarded, or learning-disabled child; and assesses social responsiveness and language development.

Note presence of physical symptoms that might indicate the existence of physical illness (e.g., rashes, upper respiratory illness, or other allergic symptoms, CNS infection [cerebritis] requiring appropriate diagnostic studies).

NURSING PRIORITIES

1. Promote client’s ability to engage in satisfying relationships with family members, peer group.

2. Facilitate parents’ development of effective means of coping with and interventions for their child’s behavioral symptoms.

3. Participate in the development of a comprehensive, ongoing treatment approach using family and community resources.

DISCHARGE GOALS

1. Demonstrates appropriate response to limits, rules, and consequences.

2. Parents have gained (or regained) the ability to cope with internal feelings and to intervene effectively in their child’s behavioral problems.

3. Therapeutic plan developed, with family and client participating in treatment program.

4. Plan is in place to meet needs after discharge.