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Oppositional Defiant Disorder Nursing Care Plan (NCP)

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

DSM-IV
313.81 Oppositional defiant disorder
312.9 Disruptive behavior disorder NOS

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

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

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

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

NURSING PRIORITIES
1. Promote client’s ability to engage in satisfying relationships with family members, peer group.
2. Facilitate parents’ development of effective means of coping with and interventions for their child’s behavioral symptoms.
3. Participate in the development of a comprehensive, ongoing treatment approach using family and community resources.

DISCHARGE GOALS
1. Demonstrates appropriate response to limits, rules, and consequences.
2. Parents have gained (or regained) the ability to cope with internal feelings and to intervene effectively in their child’s behavioral problems.
3. Therapeutic plan developed, with family and client participating in treatment program.
4. Plan is in place to meet needs after discharge.

Nursing diagnosis for Oppositional Defiant Disorder: Ineffective Individual Coping may be related to  Situational or maturational crisis; Mild neurological deficits/retardation; Retarded ego development; low self-esteem; Family system with dysfunctional coping methods, negative role models; abuse/neglect possibly evidenced by Inability to meet age-appropriate role expectations; Hostility toward others; defiant response to requests/rules; and Inability to delay gratification; manipulation of others in environment to fulfill own desires.

Desired Outcomes:
1.Demonstrate appropriate ways to assert self and establish self-worth.
2. Identify adaptive coping skills that will achieve a healthy balance between independence and dependence.
3. Delay gratification without manipulating others.

Nursing intervention with rationale:
1. Allow flexibility in shifting from one activity to another, particularly transitioning at bedtime for younger children.
Rationale: Recognizing the onset of anxiety and providing flexibility will decrease likelihood of child taking an oppositional stance.

2. Reinforce all efforts of the child when displaying efforts to establish autonomy.
Rationale: This decreases pattern of negative attention appropriate seeking behavior.

3. Provide opportunities for imaginary play, including use of puppets, clay, sand.
Rationale: The medium of play materials provides physical displacement of feelings and visualization of dynamics.

4. Set limits on disruptive behaviors (e.g., talking incessantly); suggest alternative competing behaviors such as playing quietly.
Rationale: Child needs to know expectations and to learn competing acceptable behaviors (e.g., raising hand vs. shouting out, keeping hands to self vs. pushing others).

5. Encourage discussion of angry feelings and identity of true object of hostility.
Rationale: Dealing with feelings honestly and directly helps discourage displacement of anger onto others.

6. Explore with client alternative ways for handling frustration.
Rationale: Promotes learning how to interact in society with others in more productive ways.

7. Evaluate with client the effectiveness of new behaviors. Discuss modifications for improvement.
Rationale: Because client has limited problem-solving skills, assistance may be required to reassess and develop strategies.

8. Assist client to recognize signs of escalating anxiety. Explore ways client can intervene before behavior becomes disabling.
Rationale: Helps client to recognize ineffective behaviors and develop new coping skills to effect positive change.

9. Provide positive feedback for trying new coping strategies.
Rationale: Supports efforts and encourages use of acceptable behaviors.

10. Administer medication as indicated, e.g.:
imipramine (Tofranil), paroxetine (Paxil), sertraline (Zoloft)
Rationale: Antidepressants may be used when depression is a factor in the disorder.
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