Allison Hall, MD

Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.

Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.

Discussion

Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.

We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.¹ The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.

The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.²

©kikkerdirk/Thinkstockphotos.com

There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.³ The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.

There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.⁴

Management

For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.

1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.

2. Annu Rev Nutr. 2001;21:323-41.

3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.

4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.

Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.

Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.

Discussion

Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.

We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.¹ The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.

The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.²

©kikkerdirk/Thinkstockphotos.com

There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.³ The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.

There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.⁴

Management

For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.

1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.

2. Annu Rev Nutr. 2001;21:323-41.

3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.

4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.

Emily is a 15-year-old girl who was referred by her pediatrician because of cutting behavior and conflict with her parents. Her parents reported that she has had a high body weight in the obese range since early in life. She had tried various diets without success, and her parents were frustrated with the pediatrician’s emphasis on weight over the years.

Mood problems had begun when she was in the sixth grade when she began to be severely bullied about her weight. Emily said this time was so difficult that she did not have clear memories of it. She described feeling numb. She began experiencing intense anxiety about school, and she was sometimes reluctant to attend and started cutting herself as a means of managing her emotions. In middle school, she began to fight back and associated herself with a group of “mean girls” who drank. She began having increasing conflict with her parents over the drinking and the cutting.

Discussion

Obesity is an extremely complex issue without simple answers. Severe obesity is correlated with numerous health risks including not only cardiovascular disease, type 2 diabetes, hypertension, and cancer, but also psychiatric problems such as depression, anxiety, body dissatisfaction, eating disorders, and unhealthy weight control behaviors. While some of these issues relate directly to the weight itself, many of the psychiatric concerns stem from society’s extremely harsh response to obesity.

We are all aware that the percentage of overweight and obese children, teens, and adults has increased in the past 50 years, although with some recent stabilization.¹ The rise in obesity is related to societal factors – the prevalence and advertising of nutrient-poor/high-calorie processed foods in the marketplace, the rise of technologies that have decreased the need for movement, increases in portion sizes in restaurants, especially fast food settings, as well as the subsidizing of unhealthy foods, limited access to and greater cost of more nutritious foods, and limited access to exercise opportunities in poorer areas. This is the “obesogenic environment.” As in numerous aspects of health, weight is also influenced by genetics. Those who are genetically more likely to gain weight are the ones who suffer most from these social changes.

The problem is that, except for bariatric surgery, the interventions prescribed for individuals with obesity don’t work for the vast majority of people in the long run. There is an assumption that if the obese would just eat and exercise the way a thin person does, then they would be thin. While there is evidence that lifestyle strategies that induce a negative energy balance through cutting calories (often by 500-1,000) and “programmed exercise” can help some people lose weight over the course of 6 months to a year, longer-term follow-up suggests that most people regain this weight in the long run, at 5 years out. Even the most optimistic estimates suggest that only about one out of five people can maintain weight losses of 10% in the long term with current standard lifestyle interventions.²

©kikkerdirk/Thinkstockphotos.com

There is evidence that someone attaining a particular body mass index (BMI) through dieting is not able to consume as many calories as another person who has always been at that BMI, requiring constant dietary restraint and a very high level of exercise to maintain the weight loss.³ The great majority of people who are unable to lose the weight, or briefly succeed and then gain the weight back or more, are seen as failing by society, by many medical professionals, and by themselves. There is clearly a need to focus more of our efforts on making changes on a societal level.

There also are alternative individual approaches that take the emphasis away from dieting and weight loss and instead focus on body acceptance and self-care. These interventions go by several names including mindful eating, intuitive eating, weight neutral, and “Health at Every Size.” This approach acknowledges the environmental and genetic factors beyond personal control and discusses how society pressures people to be thin. Instead of emphasizing repeated restrictive dieting, these programs stress maximizing health through making sustainable changes to increase activity and nutrition. These programs encourage people to care for themselves now rather than focusing on dieting toward a future weight where one can start enjoying life. Enjoyment of food, taking time to savor food, and being aware of when one is hungry and when not are central. For physical activity, the emphasis is on discovering something that is pleasurable and sustainable, rather than an onerous duty, as a means to an end of weight loss.⁴

Management

For Emily, struggling on the individual level, there is not a neat resolution. Psychotherapy to address anxiety, trauma, and substance abuse is indicated. Psychotherapy also should address Emily’s relationship with her body, as this is at the heart of many of these issues. Acknowledging the powerful stigma that society places on the obese while tolerating and even promoting an obesogenic environment, and the reality that weight loss is in fact extremely difficult, would open the door to a discussion with Emily and her family about what she wants and all her options to find the healthiest and most enjoyable way for her to live her life.

1. Pediatr Clin North Am. 2015 Oct;62(5):1241-61.

2. Annu Rev Nutr. 2001;21:323-41.

3. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.

4. Tylka TL, Annunziato RA, Burgard D, et al. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” J Obes. 2014;2014:983495. doi: 10.1155/2014/983495.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington.

Introduction

All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.

Case summary

A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.

Discussion

Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.

There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.

When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role

In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.

These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.

It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.

How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.

Introduction

All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.

Case summary

A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.

Discussion

Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.

There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.

When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role

In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.

These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.

It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.

How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.

Introduction

All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.

Case summary

A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.

Discussion

Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.

There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.

When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role

In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.

These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.

It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.

How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.