- What is oppositional defiant disorder
- Oppositional defiant disorder possible complications
- Oppositional defiant disorder causes
- Oppositional defiant disorder prevention
- Oppositional defiant disorder symptoms
- Oppositional defiant disorder diagnosis
- Oppositional defiant disorder treatment
- The basics of parent training programs
- Oppositional defiant disorder strategies
What is oppositional defiant disorder
Oppositional defiant disorder is a pattern of disobedient, hostile behavior and defiant behavior toward authority figures with frequent loss of temper, arguing, becoming angry or vindictive, or other negative behaviors. The essential feature of oppositional defiant disorder is a frequent and persistent pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness. It is not unusual for individuals with oppositional defiant disorder to show the behavioral features of the disorder without problems of negative mood. However, individuals with oppositional defiant disorder who show the angry or irritable mood symptoms typically show the behavioral features as well.
The prevalence of oppositional defiant disorder ranges from 1% to 11 %, with an average prevalence estimate of around 3.3%. The rate of oppositional defiant disorder may vary depending on the age and gender of the child. The disorder appears to be somewhat more more common in boys than in girls (1.4:1) prior to adolescence. This male predominance is not consistently found in samples of adolescents or adults. Some studies have shown that oppositional defiant disorder affects 20% of school-age children. However, most experts believe this figure is high due to changing definitions of normal childhood behavior. It may also possibly have racial, cultural, and gender biases. Oppositional defiant disorder typically starts by age 8. However, it may start as early as the preschool years. Oppositional defiant disorder is thought to be caused by a combination of biological, psychological, and social factors.
Symptoms of oppositional defiant disorder include:
- Actively does not follow adults’ requests
- Angry and resentful of others
- Argues with adults
- Blames others for own mistakes
- Has few or no friends or has lost friends
- Is in constant trouble in school
- Loses temper
- Is spiteful or seeks revenge
- Is touchy or easily annoyed
To fit this diagnosis, the pattern must last for at least 6 months and must be more than normal childhood misbehavior. The pattern of behaviors must be different from those of other children around the same age and developmental level. The behavior must lead to significant problems in school or social activities.
The symptoms of oppositional defiant disorder may be confined to only one setting, and this is most frequently the home. Individuals who show enough symptoms to meet the diagnostic threshold, even if it is only at home, may be significantly impaired in their social functioning. However, in more severe cases, the symptoms of oppositional defiant disorder are present in multiple settings. Given that the pervasiveness of symptoms is an indicator of the severity of the oppositional defiant disorder, it is critical that the individual’s behavior be assessed across multiple settings and relationships. Because these behaviors are common among siblings, they must be observed during interactions with persons other than siblings. Also, because symptoms of the oppositional defiant disorder are typically more evident in interactions with adults or peers whom the individual knows well, they may not be apparent during a clinical examination.
Oppositional defiant disorder is typically diagnosed around early elementary school ages and stops being diagnosed around adolescence. Kids who have oppositional defiant disorder have a well-established pattern of behavior problems. Symptoms include:
- Being unusually angry and irritable
- Frequently losing their temper / Unusually quick to lose his temper
- Being easily annoyed
- Arguing with authority figures
- Refusing to follow rules
- Ignores or rebels against rules, at home or at school
- Deliberately annoying people and be easily annoyed himself
- Blaming others for mistakes or misbehavior
- Being vindictive
- Disruptive behavior appears to be intentional rather than impulsive
- Refuses to cooperate reflexively—even before he knows what is being asked
All children can have these symptoms from time to time. What distinguishes oppositional defiant disorder from normal oppositional behavior is how severe it is, and how long it has been going on for. A child with oppositional defiant disorder will have had extreme behavior issues for at least six months.
Another hallmark of oppositional defiant disorder is the toll it takes on family relationships. Regular daily frustrations — ignored commands, arguments, explosive outbursts — build up over time, and these negative interactions damage the parent-child bond and reinforce hostile patterns of behavior.
Kids who have behavioral issues push parents towards the extremes. They push parents to become permissive and they push parents to become hyper-coercive in the hope that a larger amount of control will get the kid to listen. Neither of these extremes make for ideal parenting. It is never a parent’s intention to reinforce bad behavior, and we often don’t realize when we’re doing it. Here are two common scenarios:
- You tell your child to stop playing a game and get ready for bed. He ignores your first two requests. By the third time you ask, you’re so mad that you yell.
- You tell your child to stop playing a game and get ready for bed. He throws a tantrum because he wants to keep playing. You don’t want him to be so worked up before bedtime, so you back down and say he can play for another ten minutes — but then he has to go to bed.
In the first scenario, your child learns that yelling is an acceptable way to get a message across. More subtly, he might also be learning that he can continue ignoring those first few requests — when you escalate the situation is when he knows you’re serious.
In the second scenario, your child has learned that throwing a tantrum might give him something that he wants, so he’ll be more likely to do it again in the future.
Both of these scenarios can set families up for future conflicts, and the more they are repeated the more they become familiar patterns of behavior that are harder to break out of. Your child doesn’t have to have oppositional defiant disorder for these scenarios to happen, but repeated negative interactions like these make diagnosing a behavior disorder much more likely.
And just like parents aren’t necessarily to blame, neither are the kids. Through no conscious effort of the child, he/she learns through hundreds of trials that this is a way to continue getting what he/she wants.
This also explains why kids who have oppositional defiant disorder might act out more at home. Kids who have oppositional defiant disorder are likely to be more oppositional with people they know well, partly because the pathways are so well worn. Whereas in a place like school, where a kid has less control in general over their environment, the types of behaviors that are common to oppositional defiant disorder may not pay off as much.
Children with symptoms of this disorder should be evaluated by a psychiatrist or psychologist. In children and adolescents, the following conditions can cause similar behavior problems and should be considered as possibilities:
- Anxiety disorders
- Attention-deficit/hyperactivity disorder (ADHD)
- Bipolar disorder
- Learning disorders
- Substance abuse disorders
There is a very high overlap in kids who have ADHD who are also diagnosed with oppositional defiant disorder. Depending on the study, the overlap could be 30 to 50 percent of kids with ADHD also have oppositional defiant disorder.
Kids with ADHD are biologically loaded to be distractible, to be impulsive, to have difficulty staying in one place for a little while. So kids with ADHD start off doing things that parents perceive as off limits. And then when those kids get negative feedback they start to become even more negatively oriented towards adults. These repeated patterns of negative interactions can lead to developing oppositional defiant disorder.
But another pathway into developing oppositional defiant disorder has more to do with a child’s temperament and might be apparent early on. Children who had a lot of difficulty soothing themselves as toddlers and continue to struggle with an age-appropriate ability to control their emotions in the face of disappointment or frustration can sometimes develop oppositional defiant disorder. The adults in their environment might be more inclined to accommodate their demands in order to keep the family functioning as harmoniously as possible.
Kids who have experienced a lot of life stress and trauma are also more likely to develop oppositional defiant disorder.
It’s important to get treatment to improve the parent-child relationship, which is crucial to the health and happiness of the entire household. It is also important for your child’s future. Some children will grow out of oppositional defiant disorder, but others will continue to have behavior issues, which could lead to peer rejection and difficulty forming healthy relationships, not to mention continued family discord.
They’ll also be less likely to achieve their potential. If something doesn’t go their way, they might think it’s anyone’s fault but theirs. They might also retreat to the places where they know they can get what they want. That might mean that they try even less, push even more on the people who are closest to them, who they actually care about the most, causing even more frayed relationships.
A small percentage of kids with oppositional defiant disorder go on to develop something called conduct disorder, which is a more severe behavior disorder that includes criminal acts like stealing, setting fires and hurting people. Getting treatment sooner rather than later improves a child’s trajectory.
Oppositional defiant disorder is treatable, usually with behavioral therapy or a combination of behavioral intervention and medication.
Psychosocial management of oppositional defiant disorder involves learning skills to help build positive family interactions and to manage problematic behaviors. These include parental management training, school-based training, functional family therapy/brief strategic family therapy, and cognitive behavior therapy. Management of severe aggression and treatment of co-morbid mental health disorders are indications for pharmacotherapy. Medicines are not specifically indicated for oppositional defiant disorder, but may be administered for co-occurring conditions such as ADHD, or to help the child get the most out of therapy sessions.
Oppositional defiant disorder possible complications
In many cases, children with oppositional defiant disorder grow up to have conduct disorder as teenagers or adults. In some cases, children may grow up to have antisocial personality disorder.
Children and teenagers with oppositional defiant disorder may have trouble at home with parents and siblings, in school with teachers, and at work with supervisors and other authority figures. Children with oppositional defiant disorder may struggle to make and keep friends and relationships.
Oppositional defiant disorder may lead to problems such as:
- Poor school and work performance
- Antisocial behavior
- Impulse control problems
- Substance use disorder
Many children and teens with oppositional defiant disorder also have other mental health disorders, such as:
- Attention-deficit/hyperactivity disorder (ADHD)
- Conduct disorder
- Learning and communication disorders
Treating these other mental health disorders may help improve oppositional defiant disorder symptoms. And it may be difficult to treat oppositional defiant disorder if these other disorders are not evaluated and treated appropriately.
Oppositional defiant disorder causes
There’s no known clear cause of oppositional defiant disorder. Contributing causes may be a combination of inherited and environmental factors, including:
- Genetics — a child’s natural disposition or temperament and possibly neurobiological differences in the way nerves and the brain function
- Environment — problems with parenting that may involve a lack of supervision, inconsistent or harsh discipline, or abuse or neglect
Risk factors for oppositional defiant disorder
Oppositional defiant disorder is a complex problem. Possible risk factors for oppositional defiant disorder include:
- Temperament — a child who has a temperament that includes difficulty regulating emotions, such as being highly emotionally reactive to situations or having trouble tolerating frustration
- Parenting issues — a child who experiences abuse or neglect, harsh or inconsistent discipline, or a lack of parental supervision
- Other family issues — a child who lives with parent or family discord or has a parent with a mental health or substance use disorder
- Environment — oppositional and defiant behaviors can be strengthened and reinforced through attention from peers and inconsistent discipline from other authority figures, such as teachers
Oppositional defiant disorder prevention
There’s no guaranteed way to prevent oppositional defiant disorder. However, positive parenting and early treatment can help improve behavior and prevent the situation from getting worse. The earlier that oppositional defiant disorder can be managed, the better.
Treatment can help restore your child’s self-esteem and rebuild a positive relationship between you and your child. Your child’s relationships with other important adults in his or her life — such as teachers and care providers — also will benefit from early treatment.
Oppositional defiant disorder symptoms
Sometimes it’s difficult to recognize the difference between a strong-willed or emotional child and one with oppositional defiant disorder. It’s normal to exhibit oppositional behavior at certain stages of a child’s development.
Signs of oppositional defiant disorder generally begin during preschool years. Sometimes oppositional defiant disorder may develop later, but almost always before the early teen years. These behaviors cause significant impairment with family, social activities, school and work.
Angry and irritable mood:
- Often and easily loses temper
- Is frequently touchy and easily annoyed by others
- Is often angry and resentful
Argumentative and defiant behavior:
- Often argues with adults or people in authority
- Often actively defies or refuses to comply with adults’ requests or rules
- Often deliberately annoys or upsets people
- Often blames others for his or her mistakes or misbehavior
- Is often spiteful or vindictive
- Has shown spiteful or vindictive behavior at least twice in the past six months
Opositional defiant disorder can vary in severity:
- Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers.
- Moderate. Some symptoms occur in at least two settings.
- Severe. Some symptoms occur in three or more settings.
For some children, symptoms may first be seen only at home, but with time extend to other settings, such as school and with friends.
Oppositional defiant disorder diagnosis
To determine whether your child has oppositional defiant disorder, the mental health professional will likely do a comprehensive psychological evaluation.
To distinguish symptoms of oppositional defiant disorder from normal childhood or adolescent rebellion, the mental health professional will likely do a comprehensive psychological evaluation inclduing a detailed history of behaviors in various situations. For children younger then 5, the behaviors should occur on most days for at least 6 months; for those who are 5 or older, they should occur once a week for 6 months. Since children with oppositional defiant disorder may show symptoms only in one setting—usually at home—and are more likely to be defiant in interactions with adults and peers they know well, the symptoms may not be in evidence in the clinician’s office. Furthermore, oppositional defiant disorder often occurs along with other behavioral or mental health problems, and symptoms of oppositional defiant disorder may be difficult to distinguish from those related to other problems.
Your child’s evaluation will likely include an assessment of:
- Overall health
- Frequency and intensity of behaviors
- Emotions and behavior across multiple settings and relationships
- Family situations and interactions
- Strategies that have been helpful — or not helpful — in managing problem behaviors
- Presence of other mental health, learning or communication disorders
Oppositional defiant disorder DSM 5 diagnostic criteria
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing oppositional defiant disorder 1). The DSM-5 criteria include emotional and behavioral symptoms that last at least six months.
- A). A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.
- Angry / Irritable Mood
- Often loses temper.
- Is often touchy or easily annoyed.
- Is often angry and resentful .
- Argumentative / Defiant Behavior
- 4. Often argues with authority figures or, for children and adolescents, with adults.
- 5. Often actively defies or refuses to comply with requests from authority figures or with rules.
- 6. Often deliberately annoys others.
- 7. Often blames others for his or her mistakes or misbehavior.
- 8. Has been spiteful or vindictive at least twice within the past 6 months.
- Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8) . For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8) . While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture .
- Angry / Irritable Mood
- B). The disturbance in behavior i s associated with distress in the individual o r others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.
- C). The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.
Specify current severity:
- Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).
- Moderate: Some symptoms are present in at least two settings.
- Severe: Some symptoms are present in three or more settings.
It is not uncommon for individuals with oppositional defiant disorder to show symptoms only at home and only with family members. However, the pervasiveness of the symptoms is an indicator of the severity of the disorder.
The symptoms of oppositional defiant disorder can occur to some degree in individuals without this disorder. There are several key considerations for determining if the behaviors are symptomatic of oppositional defiant disorder. First, the diagnostic threshold of four or more symptoms within the preceding 6 months must be met. Second, the persistence and frequency of the symptoms should exceed what is normative for an individual’s age, gender, and culture. For example, it is not unusual for preschool children to show temper tantrums on a weekly basis. Temper outbursts for a preschool child would be considered a symptom of oppositional defiant disorder only if they occurred on most days for the preceding 6 months, if they occurred with at least three other symptoms of the disorder and if the temper outbursts contributed to the significant impairment associated with the disorder (e.g., led to destruction of property during outbursts, resulted in the child being asked to leave a preschool) .
The symptoms of oppositional defiant disorder often are part of a pattern of problematic interactions with others. Furthermore, individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances. Thus, it can be difficult to disentangle the relative contribution of the individual with the disorder to the problematic interactions he or she experiences. For example, children with oppositional defiant disorder may have experienced a history of hostile parenting, and it is often impossible to determine if the child’s behavior caused the parents to act in a more hostile manner toward the child, if the parents’ hostility led to the child’s problematic behavior, or if there was some combination of both. Whether or not the clinician can separate the relative contributions of potential causal factors should not influence whether or not the diagnosis is made. In the event that the child may be living in particularly poor conditions where neglect or mistreatment may occur (e.g., in institutional settings), clinical attention to reducing the contribution of the environment may be helpful.
Oppositional defiant disorder treatment
The best treatment for the child is to talk with a mental health professional in individual and possibly family therapy, but it may include other types of psychotherapy and training for your child — as well as for parents. The parents should also learn how to manage the child’s behavior. Some children respond well to treatment, while others do not.
Treatment often lasts several months or longer. It’s important to treat any co-occurring problems, such as a learning disorder, because they can create or worsen oppositional defiant disorder symptoms if left untreated.
Medications alone generally aren’t used for oppositional defiant disorder unless your child also has another mental health disorder. If your child has coexisting disorders, such as ADHD, childhood psychosis, anxiety or depression, medications may help improve these symptoms.
Psychosocial management: A popular evidence-based treatment is a type of behavior therapy called parent-child interaction therapy. The parent and child work together through a set of exercises while a therapist coaches parents through an ear bud. Parents learn to increase positive interactions with the child and to set consistent consequences for undesirable behavior. Children learn to rein in behavior and enjoy a more supportive relationship with parents.
Pharmacological treatment: Medicines are not specifically indicated for oppositional defiant disorder. However, as many children with oppositional defiant disorder have co-occurring conditions such as ADHD, they may be on medications for those other disorders. In addition, some children are so troubled by their own aggression, and their difficulties managing their painfully low frustration tolerance, that a clinician may recommend medication—like psychostimulants used to treat ADHD to help them control those responses and benefit more from behavioral therapy.
Treatment options for oppositional defiant disorder
Psychosocial management is the mainstay. Active components are as follows:
- Parental management training
- In schools, teachers’ training for behavioral interventions
- Peer group support and peer-mediated intervention
- Social awareness and supervision
- Cognitive behavior therapy: perspective taking, problem-solving skills training, assertive training, anger management training
- Functional family therapy or brief strategic family therapy
Parents play a key role in treatment for oppositional defiant disorder. This might be surprising, since children are the ones given the diagnosis, but in oppositional defiant disorder the parent-child relationship needs to be repaired, which means both parties need to make changes to get back on track.
All programs have certain goals in common, like helping parents find the middle ground between being too authoritative and too permissive. A behavioral therapist helps parents learn how to train their child’s behavior through setting clear expectations, praising kids when they follow through and using effective consequences when they don’t. Parents also learn to use these strategies consistently — one reason why behavior management strategies sometimes don’t work is because parents try different, conflicting techniques, or don’t stick to one program long enough to see gains. Parents and children will also learn problem solving skills they can rely on when they run into issues.
For management of comorbidities:
- According to the existing protocol for comorbidities
- Methylphenidate has best evidence followed by atomoxetine, and guanfacine SR, clonidine for ADHD with behavior problems
For management of aggression:
- Antipsychotic (risperidone followed by aripiprazole has the best evidence, followed by other atypical and typical antipsychotics)
- In cases of partial response, mood stabilizer can be added
- For no response, antipsychotic can be changed
The cornerstones of treatment for oppositional defiant disorder usually include:
- Parent training. A mental health professional with experience treating oppositional defiant disorder may help you develop parenting skills that are more consistent, positive and less frustrating for you and your child. In some cases, your child may participate in this training with you, so everyone in your family develops shared goals for how to handle problems. Involving other authority figures, such as teachers, in the training may be an important part of treatment.
- Parent-child interaction therapy. During parent-child interaction therapy, a therapist coaches parents while they interact with their child. In one approach, the therapist sits behind a one-way mirror and, using an “ear bug” audio device, guides parents through strategies that reinforce their child’s positive behavior. As a result, parents learn more-effective parenting techniques, the quality of the parent-child relationship improves, and problem behaviors decrease.
- Individual and family therapy. Individual therapy for your child may help him or her learn to manage anger and express feelings in a healthier way. Family therapy may help improve your communication and relationships and help members of your family learn how to work together.
- Cognitive problem-solving training. This type of therapy is aimed at helping your child identify and change thought patterns that lead to behavior problems. Collaborative problem-solving — in which you and your child work together to come up with solutions that work for both of you — can help improve oppositional defiant disorder-related problems.
- Social skills training. Your child may also benefit from therapy that will help him or her be more flexible and learn how to interact more positively and effectively with peers.
As part of parent training, you may learn how to manage your child’s behavior by:
- Giving clear instructions and following through with appropriate consequences when needed
- Recognizing and praising your child’s good behaviors and positive characteristics to promote desired behaviors
Although some parenting techniques may seem like common sense, learning to use them consistently in the face of opposition isn’t easy, especially if there are other stressors at home. Learning these skills will require routine practice and patience.
Most important in treatment is for you to show consistent, unconditional love and acceptance of your child — even during difficult and disruptive situations. Don’t be too hard on yourself. This process can be tough for even the most patient parents.
The basics of parent training programs
Despite the dizzying number of parenting books out there, sometimes parents need more support and coaching than a manual can provide. In part that’s because some kids are just more prone to challenging behaviors, and tougher to manage, than others.
Even the most charming of children can get out of control, with parents stuck in ineffectual ruts and the level of frustration and conflict mounting in the family. Sometimes behavior problems are associated with ADHD and other developmental or emotional challenges.
Kids can be noncompliant, ignoring instructions (and even direct orders) no matter how many times they’re reminded. They can be impulsive, oblivious to warnings and the rules they’re breaking. They can be oppositional and may argue back regularly. They may melt down or tantrum when asked to do something they aren’t keen on doing. All of this hurts the parent-child relationship and adds to stress on both sides.
These parent training programs are offered by psychologists and social workers, and they’ve been tested to determine exactly what techniques are most effective. Ideally, all the adults who spend a significant amount of time with the child should take the training, acknowledging that that isn’t always possible, so clinicians work with as many family members and other caregivers as they can.
What all the programs have in common is that they teach parents how to use praise, or positive reinforcement, more effectively, to encourage the behaviors they want to encourage. And they teach parents how to deploy consistent consequences when kids don’t comply. The result is that kids learn to modulate their behavior to meet expectations and enjoy much more positive interactions with their parents.
Where the programs differ is in how instruction is delivered, how parents practice the skills they’re learning, and the pace at which they’re expected to master these new skills. The programs involve 10 or more sessions, and they target different age groups of children.
These programs include:
- Parent-Child Interaction Therapy (PCIT)
- Parent Management Training (PMT)
- Defiant Teens
- Positive Parenting Program (Triple P)
- The Incredible Years.
All endorse using praise and attention to focus on positive behaviors, and all use time out in one way or another, for consequences. Regardless of the pace at which the skills are presented, the good news is that all of them have a ton of evidence behind them working.
It’s helpful for parents to understand the differences among the programs so they can pick the one they feel will work best for their family. These treatments can be matched to a child’s age, symptoms and degree of impairment.
Here’s a rundown of these types of training, what makes them different and which families they may work best for.
Parent-Child Interaction Therapy
Parent-Child Interaction Therapy works with parents and children together, teaching them skills to interact in a positive, productive way. It is effective for kids between the ages of 2 and 7, and usually requires 14 to 17 weekly sessions.
In Parent-Child Interaction Therapy, parents receive live coaching (via a bug in the ear) from a therapist who watches from behind a one-way mirror as they and their child perform a series of tasks, and parents practice specific responses to both desired and undesired behavior.
Parent-Child Interaction Therapy is the most practice-intensive, as parents demonstrate mastery of each skill before going on to the next one. It starts out with positive interactions, then waits till parents reach mastery of these skills before moving on to discipline strategies to improve oppositional behavior.
Parent-Child Interaction Therapy is recommended for parents who need a lot of one-on-one attention in terms of how they’re interacting with their child, and especially if the therapist feels like there have been a lot of coercive negative interactions. Sometimes it’s very important for parents, to learn how to be with their kid in a positive way.
Parent-Child Interaction Therapy is not just related to the child’s age range, but it’s related to the situation. If there needs to be a really strong dose of positive interactions as the first thing and the child is under 7, therapist usually lean more toward Parent-Child Interaction Therapy.
Parent Management Training
In Parent Management Training, which is for children ages 3 to 13, parents are usually seen without the child present, although children may be asked to participate in some sessions. Skills to deal more effectively with challenging behaviors are taught and modeled by the therapist and then role-played with parents. After each session, parents are expected to practice the skills at home. Families usually participate in at least 10 sessions.
In Parent Management Training there’s a new skill that’s taught at every module, so if the family really goes home and implements what was talked about in session, parent could could them all the important skills that they need to know within four or five sessions. From that point on it’s kind of tinkering, refining and tightening up everything.
Parent Management Training is usually recommended if there’s a premium on “more change more quickly.” This can be because the situation seems particularly urgent, such as really severe tantrums or aggressive behaviors.
Since Parent Management Training is appropriate for all ages, it’s a good choice when kids are too old for Parent-Child Interaction Therapy. But therapists also recommend it for a 4-year-old if they feels that the parent-child interaction is actually pretty good, but there might be other things going on, such as anxiety, extreme impulsiveness or explosive anger.
However, Parent Management Training, which establishes a token economy with point charts used to reinforce positive behaviors, can be tougher for younger kids to grasp, especially if they’re cognitively delayed. It’s sometimes hard for children to understand that they’re earning points that they can then spend on things. But if a kid is able to make the connection that they’re earning these stars for good behavior and that these stars get them a reward, then it’s appropriate.
The first half of this program involves only parents, and focuses on teaching more effective tools for interacting with their teenager, specifically for handling noncompliance or defiant behavior. But since teenagers are more autonomous than younger children and less influenced by their parents’ guidance, the program also includes training for the adolescent to help him become a participant in changing the family dynamic. In the second half, parents and teenagers are both trained in problem-solving communication. The aim is to provide family behavioral resources to help each family member develop more effective problem-solving, negotiation and communication skills and to correct any unreasonable beliefs that might be impeding their interactions.
Positive Parenting Program (Triple P)
Triple P’s focus is on equipping parents with information and skills to increase confidence and self-sufficiency in managing child behavior. It can be utilized with a wide age range of children from toddlerhood through adolescence.
There are different levels of intervention depending on how severe the case is, with more of a whole blanket system of improving parenting on many different levels.
First, for parenting basics, there’s a four-session treatment that can be given in doctor’s offices that include social workers or other mental health professionals for integrated care.
But for families with more severe behavior problems, there’s a 12-session parent-and-child-focused treatment. It incorporates the best of Parent Management Training and Parent-Child Interaction Therapy by having some sessions in which the clinician is meeting one-on-one with parents and talking about skills and strategies, and some sessions where kids are included and the therapist can do live coaching.
The Incredible Years
The Incredible Years offers small-group-based training for parents of kids from infants through age 12. The programs are broken into four age groups (baby, toddler, preschool and school age) and they range from 12 to 20 weeks.
There is also specialized training designed for high-risk socioeconomically disadvantaged families, and for families with children diagnosed with ADHD and oppositional defiance disorder (ODD).
The Incredible Years is in between Parent Management Training, where you’re given you everything up front, and Parent-Child Interaction Therapy, where skills are added only after earlier ones have been mastered.
There’s a different topic for parents each session. The program starts with a focus on improving parent-child relationships and positive attachment before moving on to consistent routines, rules, and limit-setting. Finally it covers child management strategies such as ignoring, redirection, logical and natural consequences, time to calm down and problem solving.
For children from four to eight years old, Incredible Years offers children’s groups that focus on helping them acquire emotion regulation strategies and social skills.
Research shows that the kids’ group works well at improving pro-social behavior and decreasing disruptive behaviors, but when you add the parenting part it really boosts the effectiveness of it.
One of the great things for parents is that you’ll learn not only from therapists but from each other. Parents will hear what others tried. It also normalizes what you’re seeing in your kids.
Oppositional defiant disorder strategies
At home, you can begin chipping away at problem behaviors of oppositional defiant disorder by practicing these strategies:
- Recognize and praise your child’s positive behaviors. Be as specific as possible, such as, “I really liked the way you helped pick up your toys tonight.” Providing rewards for positive behavior also may help, especially with younger children.
- Model the behavior you want your child to have. Demonstrating appropriate interactions and modeling socially appropriate behavior can help your child improve social skills.
- Pick your battles and avoid power struggles. Almost everything can turn into a power struggle, if you let it.
- Set limits by giving clear and effective instructions and enforcing consistent reasonable consequences. Discuss setting these limits during times when you’re not confronting each other.
- Set up a routine by developing a consistent daily schedule for your child. Asking your child to help develop that routine may be beneficial.
- Build time together by developing a consistent weekly schedule that involves you and your child spending time together.
- Work together with your partner or others in your household to ensure consistent and appropriate discipline procedures. Also enlist support from teachers, coaches and other adults who spend time with your child.
- Assign a household chore that’s essential and that won’t get done unless the child does it. Initially, it’s important to set your child up for success with tasks that are relatively easy to achieve and gradually blend in more important and challenging expectations. Give clear, easy-to-follow instructions.
- Be prepared for challenges early on. At first, your child probably won’t be cooperative or appreciate your changed response to his or her behavior. Expect behavior to temporarily worsen in the face of new expectations. Remaining consistent in the face of increasingly challenging behavior is the key to success at this early stage.
With perseverance and consistency, the initial hard work often pays off with improved behavior and relationships.
Managing Problem Behavior at Home
One of the biggest challenges parents face is managing difficult or defiant behavior on the part of children. Whether they’re refusing to put on their shoes, or throwing full-blown tantrums, you can find yourself at a loss for an effective way to respond.
For parents at their wits end, behavioral therapy techniques can provide a roadmap to calmer, more consistent ways to manage problem behaviors problems and offers a chance to help children develop gain the developmental skills they need to regulate their own behaviors.
ABC’s of behavior management at home
To understand and respond effectively to problematic behavior, you have to think about what came before it, as well as what comes after it. There are three important aspects to any given behavior:
- Antecedents: Preceding factors that make a behavior more or less likely to occur. Another, more familiar term for this is triggers. Learning and anticipating antecedents is an extremely helpful tool in preventing misbehavior.
- Behaviors: The specific actions you are trying to encourage or discourage.
- Consequences: The results that naturally or logically follow a behavior. Consequences — positive or negative — affect the likelihood of a behavior recurring. And the more immediate the consequence, the more powerful it is.
The first step in a good behavior management plan is to identify target behaviors. These behaviors should be specific (so everyone is clear on what is expected), observable, and measurable (so everyone can agree whether or not the behavior happened).
An example of poorly defined behavior is “acting up,” or “being good.” A well-defined behavior would be running around the room (bad) or starting homework on time (good).
Antecedents, the good and the bad
Antecedents come in many forms. Some prop up bad behavior, others are helpful tools that help parents manage potentially problematic behaviors before they begin and bolster good behavior.
Antecedents to AVOID:
- Assuming expectations are understood: Don’t assume kids know what is expected of them — spell it out! Demands change from situation to situation and when children are unsure of what they are supposed to be doing, they’re more likely to misbehave.
- Calling things out from a distance: Be sure to tell children important instructions face-to-face. Things yelled from a distance are less likely to be remembered and understood.
- Transitioning without warning: Transitions can be hard for kids, especially in the middle of something they are enjoying. Having warning gives children the chance to find a good stopping place for an activity and makes the transition less fraught.
- Asking rapid-fire questions, or giving a series of instructions: Delivering a series of questions or instructions at children limits the likelihood that they will hear, answer questions, remember the tasks, and do what they’ve been instructed to do.
Antecedents to EMBRACE:
Here are some antecedents that can bolster good behavior:
- Be aware of the situation: Consider and manage environmental and emotional factors — hunger, fatigue, anxiety or distractions can all make it much more difficult for children to reign in their behavior.
- Adjust the environment: When it’s homework time, for instance, remove distractions like video screens and toys, provide a snacks, establish an organized place for kids to work and make sure to schedule some breaks — attention isn’t infinite.
- Make expectations clear: You’ll get better cooperation if both you and your child are clear on what’s expected. Sit down with him and present the information verbally. Even if he “should” know what is expected, clarifying expectations at the outset of a task helps head off misunderstandings down the line.
- Provide countdowns for transitions: Whenever possible, prepare children for an upcoming transition. Let them know when there are, say, 10 minutes remaining before they must come to dinner or start their homework. Then, remind them, when there are say, 2 minutes, left. Just as important as issuing the countdown is actually making the transition at the stated time.
- Let kids have a choice: As kids grow up, it’s important they have a say in their own scheduling. Giving a structured choice — “Do you want to take a shower after dinner or before?” — can help them feel empowered and encourage them to become more self-regulating.
Creating effective consequences
Not all consequences are created equal. Some are an excellent way to create structure and help kids understand the difference between acceptable behaviors and unacceptable behaviors while others have the potential to do more harm than good. As a parent having a strong understanding of how to intelligently and consistently use consequences can make all the difference.
Consequences to AVOID
- Giving negative attention: Children value attention from the important adults in their life so much that any attention — positive or negative — is better than none. Negative attention, such as raising your voice or spanking — actually increases bad behavior over time. Also, responding to behaviors with criticism or yelling adversely affects children’s self-esteem.
- Delayed consequences: The most effective consequences are immediate. Every moment that passes after a behavior, your child is less likely to link her behavior to the consequence. It becomes punishing for the sake of punishing, and it’s much less likely to actually change the behavior.
- Disproportionate consequences: Parents understandably get very frustrated. At times, they may be so frustrated that they overreact. A huge consequence can be demoralizing for children and they may give up even trying to behave.
- Positive consequences: When a child dawdles instead of putting on his shoes or picking up his blocks and, in frustration, you do it for him, you’re increasing the likelihood that he will dawdle again next time.
Consequences that are more effective begin with generous attention to the behaviors you want to encourage.
- Positive attention for positive behaviors: Giving your child positive reinforcement for being good helps maintain the ongoing good behavior. Positive attention enhances the quality of the relationship, improves self-esteem, and feels good for everyone involved. Positive attention to brave behavior can also help attenuate anxiety, and help kids become more receptive to instructions and limit-setting.
- Ignoring actively: This should used ONLY with minor misbehaviors — NOT aggression and NOT very destructive behavior. Active ignoring involves the deliberate withdrawal of attention when a child starts to misbehave — as you ignore, you wait for positive behavior to resume. You want to give positive attention as soon as the desired behavior starts. By withholding your attention until you get positive behavior you are teaching your child what behavior gets you to engage.
- Reward menus: Rewards are a tangible way to give children positive feedback for desired behaviors. A reward is something a child earns, an acknowledgement that she’s doing something that’s difficult for her. Rewards are most effective as motivators when the child can choose from a variety of things: extra time on the iPad, a special treat, etc. This offers the child agency and reduces the possibility of a reward losing its appeal over time. Rewards should be linked to specific behaviors and always delivered consistently.
- Time outs: Time outs are one of the most effective consequences parents can use but also one of the hardest to do correctly. Here’s a quick guide to effective time out strategies.
- Be clear: Establish which behaviors will result in time outs. When a child exhibits that behavior, make sure the corresponding time out is relatively brief and immediately follows a negative behavior.
- Be consistent: Randomly administering time outs when you’re feeling frustrated undermines the system and makes it harder for the child to connect behaviors with consequences.
- Set rules and follow them: During a time out, there should be no talking to the child until you are ending the time out. Time out should end only once the child has been calm and quiet briefly so they learn to associate the end of time out with this desired behavior.
- Return to the task: If time out was issued for not complying with a task, once it ends the child should be instructed to complete the original task. This way, kids won’t begin to see time outs as an escape strategy.
By bringing practicing behavioral tools management at home, parents can make it a much more peaceful place to be.
How to Make Time Outs Work
Time outs are one of the most popular disciplinary tools for parents. They can be a great way to let kids know when their behavior is unacceptable without escalating the situation, which can distract kids from what you want them to learn.
But, like any tool, time outs need to be used correctly if you want them to be effective. If you’ve tried using time outs and your child doesn’t seem to be getting the message, it might be time to review how (and why) they should work.
There are a number of schools of thought about the best way to deploy them, but whichever you choose, using time outs consistently can help kids understand which behaviors aren’t (and are) appropriate and that means more positive, less fraught interactions all around.
Why use time outs?
Research shows that the most effective form of parenting is both warm and firm. That means a lot of affection and positive feedback for kids, but also consistent consequences when they act inappropriately. Time outs help you communicate that behavior is unacceptable without blowing your top.
And unlike emotional confrontations, time outs give both parties the time and space they need to calm down.
The point of a time out isn’t to shame or punish your child, but to diffuse an emotional situation, to help your child switch gears and learn to manage frustration and regulate his own behavior.
Effective time outs
Here are the basics to making the most out of time outs.
- Advance warning: Kids need to understand which behaviors are linked to which consequences. Work with your child to establish which behaviors—hitting, for instance, or not complying with instruction from you—lead to time outs so she knows what to expect.
- A pre-determined place: Designating a special chair, or a place on the stairs, also helps a child know what to expect. It’s also a good idea to label the time out chair just that, and not “the naughty chair” or something similar. Time outs work better when they are focused on teaching children how to behave, not on punishing them.
- A quick response: When a kid misbehaves in one of the ways you have discussed, make sure the following time out is immediate, and that you state the reason: “No hitting. Go to time out.” Be specific, brief, and unemotional. This helps ensure that the child is able to link her action with its consequence. Delayed consequences are ineffective because kids tend to feel you are just being punitive.
- Keep it brief: A standard formula for time outs is one minute per year of age. Some experts recommend a timer so a child can see that the time is being measured
- Keep it calm: The goal in a time out is for kids to sit quietly. Some experts recommend not starting the allotted time until your child is quiet. Others feel this is too hard for young children. They require that the child be completely quiet for 5 seconds before ending the time out. This way kids learn to associate good behaviors with the end of the time out and it sends the message to kids that yelling and screaming during a time out won’t work.
- Pay no attention: Kids in time out should be ignored—no talking to them or about them, not even gesturing in their direction, even if they’re whining, crying or protesting. By withdrawing your attention during the time out, you’re sending the message that misbehaving is not the way to get what they want
- Consistency is key: It’s tempting to put kids in time out whenever they’re acting inappropriately or pushing your buttons, but using time outs randomly makes it more difficult for kids to make the connection between specific misbehaviors and their consequences. Also, it is important that the time out occurs each and every time the specific target behavior occurs. If not, you are encouraging the child to think that he might be able to get away with it.
- No rewarding stimuli: In the time out chair the child should have no access to television, electronic devices, toys, or games. If you’re away from home, pick any spot that removes the child from distracting stimulation.
- If a child won’t stay in time out: If a child breaks the rules by leaving the time out chair too soon, put him in a backup time out area that he cannot escape from—i.e., a bedroom where there aren’t any rewarding stimuli such as television, toys, or games. Briefly explain that he must stay there for one minute and be calm and quiet before he is allowed to leave. Once he does that he should be returned to the time out chair, and the time he must stay there is restarted. If he leaves the chair again, the cycle repeats. Your child should learn quickly that it’s in his best interest to stay in the chair until the time is up.
After the time out
When kids are given time outs for not complying with your instruction, once a time out is finished, they should be asked to complete whatever task they were asked to do before the time out. This helps them understand that time outs aren’t escape routes.
Once the time out is over, you want to turn the attention back on, tuning in to whatever they are doing/working on/playing so that you can “catch them being good” and specifically praise them for a positive behavior. For example, if your child completes his time out, and then he plays gently with the dog, you’d want to let him know what he was doing right (i.e., “I love how nicely you’re playing with Lucky! You are using such nice gentle hands!”) This is reassuring your child that although he had to go to time out, he also is completely capable of doing good and positive things that make you proud and loving toward him.
How to Give Kids Effective Instructions
The first step to harmony is teaching your child to listen and follow directions.
One of the most important keys to minimizing problem behavior is making sure that kids are getting the message you’re trying to send. When it comes to parenting, sometimes the way instructions are given can be just as important as what you’re trying to communicate.
Here are ways to present information to your children to make it more likely that they’ll hear you, and comply:
- Be direct. Make statements rather than asking questions: “Please sit down,” as opposed to “Are you ready to get out your homework?”
- Be close. Give instructions when you are near the child, rather than calling out from across the room.
- Use clear and specific commands. Instead of “Go ahead,” say, “Please go start your reading assignment.”
- Give age-appropriate instructions. Speak to your child at a level he will understand. If your child is younger, keep things simple and use words you know he knows: “Please pick up the ball.” With older children, who are so often keenly aware of not being “babies anymore” it’s important to be clear without being patronizing.
- Give instructions one at a time. Especially for kids who have attention challenges, try to avoid giving a series of instructions: “Please put on your sneakers, get your lunch off the kitchen counter, and meet me in the front hall.
- Keep explanations simple. Giving a rationale can increase the likelihood children will listen to a command, but not if the commands gets lost in it. For instance: “Go get your coat on because it’s raining and I don’t want you to catch a cold.” Instead, try: “It’s raining and I don’t want you to catch a cold. Go get your coat on.”
- Give kids time to process. After you give an instruction, wait a few seconds, without repeating what you said. Children then learn to listen to calm instructions given once rather than learning that they don’t need to listen because the instructions will be repeated. Watching and waiting also helps keep adults from doing what we’ve requested of our kids for them.
Dealing With Explosive Behavior
When a child—even a small child—melts down and becomes aggressive, he can pose a serious risk to himself and others, including parents and siblings.
It’s not uncommon for kids who have trouble handling their emotions to lose control and direct their distress at a caregiver, screaming and cursing, throwing dangerous objects, or hitting and biting. It can be a scary, stressful experience for you and your child, too. Children often feel sorry after they’ve worn themselves out and calmed down.
So what are you to do?
It’s helpful to first understand that behavior is communication. A child who is so overwhelmed that he is lashing out is a distressed child. He doesn’t have the skill to manage his feelings and express them in a more mature way. He may lack language, or impulse control, or problem-solving abilities.
Sometimes parents see this kind of explosive behavior as manipulative. But kids who lash out are usually unable to handle frustration or anger in a more effective way—say, by talking and figuring out how to achieve what they want.
Nonetheless, how you react when a child lashes out has an effect on whether he will continue to respond to distress in the same way, or learn better ways to handle feelings so they don’t become overwhelming. Some pointers:
- Stay calm. Faced with a raging child, it’s easy to feel out of control and find yourself yelling at him. But when you shout, you have less chance of reaching him. Instead, you will only be making him more aggressive and defiant. As hard as it may be, if you can stay calm and in control of your own emotions, you can be a model for your child and teach him to do the same thing.
- Don’t give in. Don’t encourage him to continue this behavior by agreeing to what he wants in order to make it stop.
- Praise appropriate behavior. When he has calmed down, praise him for pulling himself together. And when he does try to express his feelings verbally, calmly, or try to find a compromise on an area of disagreement, praise him for those efforts.
- Help him practice problem-solving skills. When your child is not upset is the time to help him try out communicating his feelings and coming up with solutions to conflicts before they escalate into aggressive outbursts. You can ask him how he feels, and how he thinks you might solve a problem.
- Time outs and reward systems. Time outs for nonviolent misbehavior can work well with children younger than 7 or 8 years old. If a child is too old for time outs, you want to move to a system of positive reinforcement for appropriate behavior—points or tokens toward something he wants.
- Avoid triggers. Dost kids who have frequent meltdowns do it at very predictable times, like homework time, bedtime, or when it’s time to stop playing, whether it’s Legos or Nintendo. The trigger is usually being asked to do something they don’t like, or to stop doing something they do like. Time warnings (“we’re going in 10 minutes”), breaking tasks down into one-step directions (“first, put on your shoes”), and preparing your child for situations (“please ask to be excused before you leave Grandma’s table”) can all help avoid meltdowns.
What kind of tantrum is it?
How you respond to a tantrum also depends on its severity. The first rule in handling nonviolent tantrums is to ignore them as often as possible, since even negative attention, like telling the child to stop, can be encouraging.
But when a child is getting physical, ignoring is not recommended since it can result in harm to others as well as your child. In this situation, putting the child in a safe environment that does not give her access to you or any other potential rewards.
If the child is young (usually 7 or younger), try placing her in a time out chair. If she won’t stay in the chair, take her to a backup area where she can calm down on her own without anyone else in the room. Again, for this approach to work there shouldn’t be any toys or games in the area that might make it rewarding.
Your child should stay in that room for one minute, and must be calm before she/he is allowed out. Then she/he should come back to the chair for time out. What this does is gives your child an immediate and consistent consequence for her/his aggression and it removes all access to reinforcing things in her/his environment.
If you have an older child who is being aggressive and you aren’t able to carry her into an isolated area to calm down, removing yourself from her vicinity. This ensures that she is not getting any attention or reinforcement from you and keeps you safe. In extreme instances, it may be necessary to call your local emergency number to ensure your and your child’s safety.
Help with behavioral techniques
If your child is doing a lot of lashing out—enough that it is frequently frightening you and disrupting your family—it’s important to get some professional help. There are good behavioral therapies that can help you and your child get past the aggression, relieve your stress and improve your relationship. You can learn techniques for managing his behavior more effectively, and he can learn to rein in disruptive behavior and enjoy a much more positive relationship with you.
- Parent-child interaction therapy. Parent-child interaction therapy has been shown to be very helpful for children between the ages of 2 and 7. The parent and child work together through a set of exercises while a therapist coaches parents through an ear bud. You learn how to pay more attention to your child’s positive behavior, ignore minor misbehaviors, and provide consistent consequences for negative and aggressive behavior, all while remaining calm.
- Parent Management Training. Parent Management Training teaches similar techniques as Parent-child interaction therapy, though the therapist usually works with parents, not the child.
- Collaborative and Proactive Solutions. Collaborative and Proactive Solutions is a program based on the idea that explosive or disruptive behavior is the result of lagging skills rather than, say, an attempt to get attention or test limits. The idea is to teach children the skills they lack to respond to a situation in a more effective way than throwing a tantrum.
Figuring out explosive behavior
Tantrums and meltdowns are especially concerning when they occur more often, more intensely, or past the age in which they’re developmentally expected—those terrible twos up through preschool. As a child gets older, aggression becomes more and more dangerous to you, and the child. And it can become a big problem for him at school and with friends, too.
If your child has a pattern of lashing out it may be because of an underlying problem that needs treatment. Some possible reasons for aggressive behavior include:
- ADHD: Kids with ADHD are frustrated easily, especially in certain situations, such as when they’re supposed to do homework or go to bed.
- Anxiety: An anxious child may keep his worries secret, then lash out when the demands at school or at home put pressure on him that he can’t handle. Often, a child who “keeps it together” at school loses it with one or both parents.
- Undiagnosed learning disability: When your child acts out repeatedly in school or during homework time, it could be because the work is very hard for him.
- Sensory processing issues: Some children have trouble processing the information they are taking in through their senses. Things like too much noise, crowds and even “scratchy” clothes can make them anxious, uncomfortable, or overwhelmed. That can lead to actions that leave you mystified, including aggression.
- Autism: Children on all points of the spectrum are often prone to major meltdowns when they are frustrated or faced with unexpected change. They also often have sensory issues that make them anxious and agitated.
Given that there are so many possible causes for emotional outbursts and aggression, an accurate diagnosis is key to getting the help you need. You may want to start with your pediatrician. She can rule out medical causes and then refer you to a specialist. A trained, experienced child psychologist or psychiatrist can help determine what, if any, underlying issues are present.
When behavioral plans aren’t enough
Professionals agree, the younger you can treat a child, the better. But what about older children and even younger kids who are so dangerous to themselves and others, behavioral techniques aren’t enough to keep them, and others around them, safe?
- Medication. Medication for underlying conditions such as ADHD and anxiety may make your child more reachable and teachable. Kids with extreme behavior problems are often treated with antipsychotic medications like Risperdal or Abilify. But these medications should be partnered with behavioral techniques.
- Holds. Parent training may, in fact, include learning how to use safe holds on your child, so that you can keep both him and yourself out of harm’s way.
- Residential settings. Children with extreme behaviors may need to spend time in a residential treatment facility, sometimes, but not always, in a hospital setting. There, they receive behavioral and, most likely, pharmaceutical treatment. Therapeutic boarding schools provide consistency and structure round the clock, seven days a week. The goal is for the child to internalize self-control so he can come back home with more appropriate behavior with you and the world at large.
- Day treatment. With day treatment, a child with extreme behavioral problems lives at home but attends a school with a strict behavioral plan. Such schools should have trained staff prepared to safely handle crisis situations.
Explosive children need calm, confident parents
It can be challenging work for parents to learn how to handle an aggressive child with behavioral approaches, but for many kids it can make a big difference. Parents who are confident, calm, and consistent can be very successful in helping children develop the skills they need to regulate their own behavior.
This may require more patience and willingness to try different techniques than you might with a typically developing child, but when the result is a better relationship and happier home, it’s well worth the effort.
Coping and support
It’s challenging to be the parent of a child with oppositional defiant disorder. Ask questions and try to effectively communicate your concerns and needs to the treatment team. Consider getting counseling for yourself and your family to learn coping strategies to help manage your own distress. Also seek and build supportive relationships and learn stress management methods to help get through difficult times.
These coping and support strategies can lead to better outcomes for your child because you’ll be more prepared to deal with problem behaviors.
References [ + ]
|1.||↵||American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 5. Washington, DC: American Psychiatric Association; 2013.|