MIAMI BEACH – It is important to confront parents about their parenting style when conveying a diagnosis of oppositional defiant disorder, a developmental pediatrics specialist advises.
It is difficult to address a parenting issue, particularly in a 15-minute visit and when you want to keep a relationship with the family, Dr. David O. Childers, chief of the developmental pediatrics section at the University of Florida, Jacksonville, told the annual Masters of Pediatrics conference. Instead, ask them to return for a more comprehensive discussion, perhaps as the last appointment on a day in the near future. “When I make the diagnosis, I don't just throw them out the door. I spend 45 minutes to an hour to speak with parents about options and things they could do better,” Dr. Childers said.
Parenting class is an important strategy regarding oppositional defiant disorder (ODD), one that Dr. Childers knows from personal experience. “A parenting class is essential. In the world of behavioral medicine, good parenting style is very important. When I walked out of my parenting class, I said, 'Man, I didn't know what I was doing.' My wife and I were not good parents when our son was 5 years old,” he said.
Dr. Childers typically tells parents three things about ODD. “No. 1–my son got diagnosed with ODD at age 5 and it was a good, valid diagnosis. No. 2–you're going to hate my third thing. And No. 3–it's a mismatch between the parents and the child … when the parenting abilities suck.”
Discipline and consistency are critical to improve life for a family affected by ODD, Dr. Childers said at the conference sponsored by the University of Miami.
Discipline is also important for parents, he said. They “have to be consistent over time. Kids are screaming for boundaries and rules. They don't know this is what they want, but they do. Kids get irritable when the boundaries are shifting all the time.”
A short period of negative reinforcement helps parents gain control over the inappropriate behavior so they can implement positive changes over time. Dr. Childers said, “I tell parents it's going to be 1 or 2 months of miserable existence to buy the next 10 or 15 years of happiness.”
“For most children who are coming to my level of care,” he added, “it takes a few weeks to a month or two for the child to realize the parent is not going to break.”
Sending a child to the corner for a “time out” is a component of the negative reinforcement. “The 'corner' is available everywhere you go. You can take them out of a restaurant and put their nose to the side of the building, or if you are driving you can pull into the next parking lot,” Dr. Childers said. This strategy will alter future behavior for a majority of children.
In some rare cases, he added, medications to reduce the child's irritability are warranted to give parents a better opportunity to address the bad behaviors.
If a child ever says “no” or argues with a parent, they get an automatic time out, Dr. Childers said. In addition, if they show any kind of disrespect, such as ignoring parents or rolling their eyes, “they go right to the corner.” Any type of aggressive behavior likewise is not tolerated.
Advise parents not to count to three because it implies the child has time to think about it. “I tell the parents if they want to count to three, start with three and then go right to time out,” Dr. Childers said.
Warn parents that during the negative reinforcement phase, the child's behaviors will escalate and continue to escalate until the moment they realize the parent is not going to back down, he said.
Empathizing with parents can help. “I tell parents it is not easy but they will end up with a dramatically calmer and happier child. I know that sometimes children will wear them down, or they are stressed out, and they will give the child a 'fine, whatever.' The 'fine, whatever' could be 'go ahead, have a chocolate bar for dinner' or 'go ahead, go play video games.' However, it is essential not to back down no matter how challenging the situation. They know they will get 10 more 'fine, whatevers' from the parent if they keep up the behavior. Parents have to be absolutely consistent … and they will be able to move from negative reinforcement to a positive behavior.”
“I tell parents it may take 1–2 months to gain control. However, it usually takes 1–2 weeks. I prepare them for the longer haul so they won't give up in case they have one of the outlier children who really do take several months. So, in general, families who come to see me can move pretty rapidly to a positive reward system, which should be the heart of any behavior program,” he said.