اختلالات مخالف کودک و طغیان درونی خانوادگی: به سوی فردی شدن انواع بالینی

Oppositional defiant disorder (ODD) is a frequent but heterogeneous diagnostic category describing a wide range of children with problematic behaviours of non-compliance and defiance towards carriers of authority. ODD is estimated to affect 5–10% of youngsters. Children with ODD show a sustained pattern of hostile, argumentative, disobedient and resentful behaviours. These behaviours may be pervasive or limited to family interactions. We identified children whose symptoms were directed mainly towards their parents, with a particular family context characterized by an inversion of the family hierarchy. Although ODD has no recognized subtypes, intra-familial ODD with tyrannical behaviours may be associated with specific developmental pathways and co-morbidity patterns. ODD with tyrannical behaviours is not identified as such in the nosography but has been described by several clinicians (Dugas 1985). Its main clinical features are: repeated physical and psychological abuse and familial dysfunction characterized by an inversion of familial authority. The child is usually considered the most important person of the family, taking important decisions in place of his parents who avoid exposing him to frustration and limits in his education. Typically, aggressive outbursts appear or worsen when parents make efforts to regain their control over the child. Physical abuse is not always present but psychological constraint is frequent in clinical descriptions (i.e. the child threatens suicide, leaving home…). Parents often give in because they fear losing the affection of their child. The objective of our study was to carry out a retrospective chart study to compare clinical, therapeutic and socio-demographic characteristics in two groups of children, one having ODD without familial tyranny (N = 23), the other having ODD with familial tyranny (N = 22). Children were matched for age and sex. The mean age of the sample was 10 years. There were a majority of boys in both groups. Results show differences in socio-demographic characteristics, with more tyrannical children coming from middle or upper class families. The age of parents at childbirth is higher in the group of ODD with tyranny (37 years for fathers and 32 for mothers vs. 34 and 28). No differences were found with adopted and medically procreated children. There was a non-significant trend towards more medical or psychiatric antecedents in the group of ODD with tyranny; there were also slightly more single or elder children among siblings in this group. In the ODD group, targets of aggressive behaviour were diverse (teachers, parents, siblings…) whereas the mother was the preferential target in children with tyrannical ODD. Tyrannical children also used more physical violence than children with ODD alone. There were no differences in co-morbidity between groups but children with tyrannical ODD showed significantly higher IQs. Results are discussed in terms of psychopathological hypotheses derived from clinical observations and the sparse published data on this particular form of intra-familial violence. Our findings of socio-demographic and clinical characteristics of families with tyrannical children are corroborated by available clinical descriptions (Dugas 1985, Paulson 1990). They may foster a vulnerability of parental authority and give the child a particular position in the family dynamics. It seems that in a majority of these families, the child is a particular “precious” one, long awaited for. The greater age of the parents, their physical and medical problems, and their excessive intellectualisation of children’s problem behaviours may weaken their authority and effectiveness in setting limits. Our study showed significant differences between ODD and ODD with tyranny that may have etiologic and prognostic importance.