Case Study - David

This case study is a composite of several real children I have treated in the past 7 years. Names have been changed, but the story is based on real events that actually happened with different children and parents I have worked with.

A 6-year old boy with severely oppositional defiant behavior, anger, aggression and refusal to follow instructions.

David was a 6-year old first grader who was unusually tall for his age. His parents both came to me quite exasperated and at the end of their rope. “I just don’t see how it’s possible to get him to do anything!” his father expressed. “Everything is NO.” David was refusing to brush his teeth, and it had gotten to the point that his mother had to sometimes literally force him to brush! David was also alarmingly aggressive. He would often hit his mother when he didn’t get what he wanted, such as extra TV or junk food. His father was forced to be very stern and punitive with him, as it seemed to be the only way to overcome David’s resistance, get him to comply and limit his aggression. In school he was hyperactive and inattentive and had difficulty following directions.

I explained to them that their problem had a solution, and it would require maybe 5-9 months of Play Therapy together with Parenting Counseling.

The Parenting Counseling would need to be done very gradually, as I would need time to get to know them and develop a therapeutic alliance, or close working relationship. I illustrated that it was like a doctor who prescribed one drop of medicine for 14 days. Would you say, “I’m going to get better real fast by taking all 14 drops in one day!” Would that work? Parenting Counseling was the same way. Instead of telling them what to do, I needed to help them to discover from within their own minds the wisdom necessary to resolve the issue. This would be done through what is called Socratic Questioning, gently guiding them towards developing their own solutions. Since they would create such solutions themselves, they would be much more likely to cherish and abide by them. We agreed to alternate sessions, one week Mom would come, and one week Dad, as they couldn’t always come both at the same time due to difficulties finding a babysitter.

I asked them to fill out the Compliance with Commands Worksheet, a tool I have developed to deal with defiance. Here it is:  

The Compliance with Commands Worksheet

  1. Please put a line or a check here every time you perform any kind or Parenting Intervention, such as issuing a “Do” or a “Don’t,” making a command, a request, or exercising any parental authority. Count the total at the end of the day:
  2.  Now kindly estimate whether you feel each command was completely non-negotiable, which means it must be carried out at all costs, or whether you could actually be flexible, and possibly give in and cut out that particular intervention, and still run a reasonable organized household. Estimate which percent of the commands are non-negotiable, and which are flexible:
  3. Now kindly record how many times the child complied with the command or request without too much conflict or unpleasantness, and how many times he or she did not or he did but with significant conflict:
  4. Now compare the numbers. For example, let’s say you issued 100 commands throughout the course of the day and the child complied with 50. 75 were important, non-negotiable items, and 25 were flexible. The point, which we will discuss in session, is that if you eliminate the 25 flexible commands, you won’t be losing much, because he or she already is only complying with 50. But the benefit will be that by giving in on 25, the child will feel much less resentment and restriction, and will more happily comply with at least the same 50, and I predict he will even be much more willing to comply with all 75 non-negotiables!
  5. On another day, after discussing all this with me, and you have cut out as many flexibles as possible, recount how many commands you issued, how many were non-negotiable or flexible, and how many the child complied with, and discuss the results with me.

Please be advised that the above will take a bit of time to work, and requires simultaneously developing Parenting ideas such as raising the child’s overall happiness level, and a regimen of Play Therapy, in order to be most effective.

David’s parents were sincere and motivated, and brought me the results the next week.

It turned out they had issued to David approximately an astounding 200 commands in one day! Even they were surprised it added up to so much. Approximately 125 times he refused to comply with those directives, to which they often responded with threats, punishments and shouting.

I asked them how they would feel if their boss would come into their office 200 times a day with an order, “Make this copy!” or “Do this paperwork!” How eager would they be to comply? Then I asked them to imagine how similarly, David might be feeling. They began to see that he might actually be resenting so many Parenting Interventions, and maybe that was creating resistance. “But there are things he simply must do!” they exclaimed. “We can’t just let them do whatever he wants!” He had complied with maybe 75 commands, and they estimated that about 125 were non-negotiable. Then I explained to them an amazing trick, that by actually reducing the number of Parenting commands issued, resentment and resistance is reduced, and it actually increases compliance with the fewer remaining commands! This was all discussed over the course of a few sessions, in order to gradually get them used to the new ideas. They agreed to try to reduce Parenting Interventions, but which ones were really flexible? So we picked out the small stuff. Maybe it’s not so bad if he bounces a small ball in the living room. Resist the urge to command him to stop. Skip the order to wash his hands with soap before every meal. How many adults actually do that every time? Abandon the idea of forcing him to make his bed every morning. It is too much to expect from a 6-year old! If he’s singing loudly or shouting? Ignore it or go into the other room. Don’t waste a precious command on small stuff! Save your commands for important items like not hitting, not playing with the stove or knives, or not running into the street.

I helped David’s parents to realize that children are desperately trying to reach that great, golden goal: self-determination. We as parents need to make ourselves small so that they can grow big. We have to give them a bit more breathing room. Limits need to be set, but by reducing them as much as possible, we actually increase compliance. Let’s say David could handle 50 parenting interventions per day and more or less comply, leaving his self-determination intact. But let’s say his parents are regularly issuing 55 per day, they’ve gone beyond his limit, and frustration, resentment, resistance and rebellion will build up. But bringing it down to 50 puts David into his comfort zone and he will happily comply with all 50!

I taught them another great trick to avoid wasting precious commands unnecessarily. It was developed by Haim Ginott, famed psychologist from the 70’s, called describing and giving information.

Let’s say David comes home and throws his coat on the floor instead of hanging it up like he’s supposed to. Instead of commanding, “Hey, hang that up!” which will make him feel bossed and resentful, wait a couple of minutes and then gently describe, “I see a coat on the floor,” and you’d be amazed to see him pick it up! You see, describing allows the child to save face and avoid the ego-deflation of being given orders. You’re just giving information and allowing him himself to conclude what the right thing to do is. Describing honors the child, because we are in effect saying, “I trust you to make the right decision.” That pleasure inspires the child to comply.

Later David had eaten an orange on the leather couch, and left the peels there. His father resisted the urge to say, “Clean those up right now!” He tried describing matter-of-factly “I see orange peels on the couch!” He couldn’t believe his eyes when David scurried to pick them up and put them in the garbage. When homework time came, instead of ordering, “Go get a pencil,” Mom simple described, “I see a pencil on the table over there,” and David could figure out by himself that he needs to go get it.

In addition David came for Child-Centered Play Therapy sessions weekly. In the playroom, I didn’t tell David what to do at all. He was completely in the driver’s seat, and I followed him, supporting, respecting and celebrating all his decisions. This was so thrilling to him, that he could be the boss of his own institution, his weekly Play Therapy session. I showed so much respect for him, that he learned to respect himself, and to honor his own feelings, needs and desires. All this made him feel so good about himself over time, that he became more willing to comply with his parents and easier to manage at home.

David expressed a lot of aggression in play. He constantly tried to shoot me with the harmless dart gun I have. I set a limit on that, redirecting him to shoot toy soldiers, and other things. He would make mock battles with the Bobo, (a punching bag I have) Smash rubber animals with the toy hammer, and build and knock down towers. All this helped him to express his aggression in a healthy and acceptable manner, having it accepted and validated by his empathetic therapist.

After several months of getting to know David’s parents, I explained to them that too many commands make a child feel overly restricted and this feels to them like aggression, as they feel aggressively limited in their behaviors. This in turn causes them to act out aggressively towards parents and others. Reducing commands would greatly reduce aggression. Experiencing the opposite of restriction and aggression, the self-determination, empowerment and empathy of the playroom, would further reduce it.

Indeed after 6 months of treatment, David’s parents reported what they would describe as 40% improvement. He was more agreeable at home, and less defiant. His aggression was significantly reduced. The parents began to feel like a solution was possible.

We worked on the problem of brushing the teeth. I helped them to see that although dental hygiene was important, physically forcing a child to brush was so damaging to his emotional health and to the parent-child relationship, that it was far worse than the chance of a few cavities. After all, cavities, if detected early, could easily be filled, and most of his teeth are going to fall out anyway! Therefore I helped them see the wisdom of a plan where they would stop asking David to brush his teeth altogether for one month. (Cavities take many months and years to develop) This would allow his resentment and resistance to dissipate. Then they began by encouraging him very gently to brush only once or twice a week, and offering him an extra video every time he brushed. I think that by the time he left therapy they had him brushing more or less 3 times a week, but willingly and without much conflict!

David’s parents had limited him to 30 minutes of screen time per day total, they felt it was bad for him. This made him absolutely desperate for more screen time, as all his friends got several hours of it per day and he felt terribly deprived. I helped his parents see that every child needs 3-4 hours of intense happiness and pleasure every day, in order to grow up emotionally healthy. If you can give it through sports, activities, games, playdates or toys, great. But nowadays, screens is the activity of choice for all children, and they must get a reasonable amount, at least close to what their friends are getting. I explained that by making David happy they are performing a tremendous act of kindness towards him, and that great example will turn him into a kind person!

I commend David’s parents because they diligently attended therapy for a full 9 months, at which point they described the situation as 60 percent improved. He was much less defiant, and an atmosphere of pleasantness and joy had begun to pervade their home. Teachers reported improved behavior in school, and most importantly there was much more shared delight in the relationship between parents and child.