Category Archives: oppositional defiant disorder

Take this parenting test if you have a troubled teenager

Take this parenting test if you have a troubled teenager
1 votes

So how are you doing in this parenting job you have?  Score your parenting skills on a test designed for parents of children ages 11-15 with serious behavior problems.  (If you are brave, have someone else score you too and compare notes.)

Always: 5    Generally: 4    Sometimes: 3    Rarely: 2    Never: 1 Your
score
1.    My child’s other parent (or caregiver) and I agree on how to discipline our child.  


2.    My child can depend on me to do what I say I will.
3.    When I say “no”, I stick to it.
4.    I treat my child with respect, even when I’m angry.
5.    I let natural consequences do the teaching whenever feasible.
6.    I am confident my child has everything she/he needs to make
good decisions.

7.    I allow my child to do his/her chores without my reminding.
8.    I allow my child to voice her/his opinions when done in a
respectful way.

9.    I am able to stay out of arguments by disengaging before they
escalate.

10: When I make a mistake in judgment, I’m quick to admit it.
TOTAL

SCORE

45 – 50   Good job!  You are on the right track.
30 – 45   Not bad, just a little more work in those challenging areas.
Less than 30  Keep trying!  Find a support group; a therapist for you and a co-parent; or books (recommendation).

Don’t be hard on yourself if you score low.
Teenagers are difficult.

You might be thinking:  “I agree these are good parenting skills, but practicing them is impossible with my child.  They hate/defy/scream at me constantly.”  Advice: Work on one at a time, and check back in few weeks to see if you’ve improved your score.

This test is drawn from a parenting guide created in 2007 by StandUp Parenting (www.standup.org)
to help parents understand what is needed to maintain authority and model maturity.  

Please add a comment if you have found other skills to be effective,

Margaret

 

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What to know about psychiatric residential treatment

What to know about psychiatric residential treatment
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residential centerHave you been searching for psychiatric residential treatment for your child?  Do all the programs sound wonderful?  Ads include quotes from happy parents, and lovely photos and fabulous-sounding activities.  But what’s behind the ads?  Residential treatment programs are diverse, but there are important elements they should all have.  Here’s how to avoid low quality residential treatment.

Psychiatric residential treatment is serious stuff–it’s difficult to do–especially when troubled children and teens are put together in one facility.

Should you ask other parents for their opinion of a program?  In my experience with a child in psychiatric residential care, and as a former employee of one, word-of-mouth is not the best way to assess quality or success rate.  There are too many variables: children’s disorders are different; acuity is different; parents’ attitudes and expectations are different; length of time in the facility is different; what happens once a child returns home is different…  It’s most helpful to ask questions of intake staff and doctors or psychologists on staff.  Quality psychiatric residential care facilities have important things in common.

What to ask about the staff:

copy

  • What is the training and licensure of staff?  Are there therapists with MSW degrees, registered nurses, psychiatrists and psychiatric nurse practitioners, and is a medical professional available on site 24/7?
  • There should be a high staff to patient ratio, and a physically comfortable environment with lots of emotional support.
  • Do the staff seem mature to you?  Do they support each other, are they a team?  There is often heavy staff turnover at residential treatment centers because the work is emotionally draining, so staff cohesion is as important as the qualities of each individual.
  • Safety is paramount.  Staff must be able to safely manage the things that can go wrong with troubled kids.  They should be trained in NCI (Nonviolent Crisis Intervention), “training that focuses on prevention and offers proven strategies for safely defusing anxious, hostile, or violent behavior at the earliest possible stage.”

What to ask about programs:

  • Does the program specifically identify parent/family involvement as part of treatment?  Does it emphasize parent partnership with staff?  Ask.  Whether you live close or far from the center, even out-of-state, you should be regularly included in conversations with staff about your child’s treatment.  You should also be included in a therapy session with your child periodically; some facilities can connect with you over Skype.  Your child’s success in psychiatric care depends on their family’s direct involvement.
  • The program should coach you in specific parenting approaches that work for child’s behavioral needs.  While your child is learning new things and working on their own changes, you must also.
  • You should be informed why your child is getting the treatment or behavioral modifications he/she is receiving.

Body health is mind health, and vice versa.

  • residential programsMental health treatment will include medication and therapy, but must also include positive activities and an educational program.  The whole body needs care:  exercise, social activities, therapeutic activities (art, music, gardening), healthy food, restful sleep, etc.

Is your child emotionally safe as well as physically safe?

  • You should be able to visit the unit or cottage where your child will live, see their bedroom, and see how the other children interact with staff and how staff interact with each other.

What to ask about the business itself:

  • Can you take a tour ahead of time?  Can your child or teen visit too if appropriate?
  • Are emergency services nearby (hospital, law enforcement) that can arrive quickly?
  • Does the facility have a business license in their state?  Do they have grievance procedures?  Is the center accredited as a treatment facility, and by whom?  In the U.S., the main accreditation authority is called JCAHO (Joint Commission on Accreditation of Healthcare Organizations).

Psychiatric residential treatment works miracles, but it doesn’t work for all children.  Some need to go into treatment more than once to benefit. Some fall apart a few weeks or months after discharge.  These are common.  What’s important is that you and your child are taught skills for managing his or her unique symptoms, communicating well, and committing to staying well together.

Good luck.

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Is my teen ‘normal’ crazy or seriously troubled?

Is my teen ‘normal’ crazy or seriously troubled?
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photo8A high percentage of teenagers go through a rebellious or irrational phase that is quite normal for their age and brain development.  The difference between normal teen craziness and abnormal behavior is when the teenager falls behind his or her peers in multiple key areas.  At a bare minimum, a normal teen should be able to do the following:

  • Attend school and do most school work if they want to;
  • Have and keep a friend or friends their own age who also attend school;
  • Have a maturity level roughly the same as his or her peers;
  • Exercise self-control when he or she wants to;
  • Have basic survival instincts and avoid doing serious harm to themselves, others, or property.

photo5It is normal for teens to be inconsistent, irrational, insensitive to others, self-centered, and childish.  Screaming, for example, is normal–regard this the same as a toddler temper tantrum.  It is a phase that most teens grow out of unless something else is holding them back.

This is your challenge:  even teens with mental disorders have some normal teenage behavior traits like those listed above.  How do you tell which is which so you can get help?  Look for pervasive patterns of social and behavioral problems that are more serious, and in almost all settings.  The patterns repeat and the outcomes are increasingly worse.

photo2

Some signs of abnormal unsafe* behavior

*Unsafe” means:  there’s a danger of harm to themselves or others, property loss or damage, running away, seeking experiences with significant risk (or easily lured into them), abusing substances, and physical or emotional abuse of others.

  • If a troubled teenager does something unsafe to themselves or others, it is not on impulse or an experiment, but is intentional and planned.
  • They have a prior history of intentional unsafe activities.
  • They have or seek the means to do unsafe activities.
  • They talk about or threaten unsafe behavior.
  • There are others who believe there is something abnormal or unsafe about your child.  (e.g., your child’s friend comes forward, their teacher calls, other parents keep their children from your child, or someone checks to see if you’re aware of the nature of his or her behaviors).


photo7How psychologists measure the severity of a child’s behavior 

“Normal” is defined with textual descriptions of behaviors, and these are placed on a spectrum from normal to abnormal (“severe emotional disturbance”).  Below are a few examples of a range of behaviors in different settings.  These descriptions are generalizations and should not be used to predict your child’s treatment needs, but they do offer insight into severity and the need for mental health treatment.

School behaviors

Not serious – This child has occasional problems with a teacher or classmate that are eventually worked out, and usually don’t happen again.

Mildly serious – This child often disobeys school rules but doesn’t harm anyone or property.  Compared to their classmates, they are troublesome or concerning, but not unusually badly behaved.  They are intelligent, but don’t work hard enough to have better grades.

Serious – This child disobeys rules repeatedly, or skips school, or is known to disobey rules outside of school.  They stand out as having chronic behavior problems compared to other students and their grades are always poor.

Very serious – This child cannot be in school or they are dangerous in school.  They cannot follow rules or function, even in a special classroom, or they may threaten or hurt others or damage property.  It is feared they will have a difficult future, perhaps ending up in jail or having lifetime problems.

photo6Home behaviors

Not serious – This child is well-behaved most of the time but has occasional problems, which are usually worked out.

Mildly serious – This child has to be watched and reminded often, and needs pushing to follow rules or do chores or homework.  They don’t seem to learn their lessons and are endlessly frustrating.  They can be defiant or manipulative, but their actions aren’t serious.

Serious – This child does not want to follow rules, even reasonable rules.  They take no responsibility for their behavior, which can include swearing and damage to the home or property.  They will do and say anything to get their way.

Very serious – The stress caused by this child means the family cannot manage normally at home even if they work together.  Running away, damaging property, threats of suicide or violence to others, and other behaviors require daily sacrifices from all.

photo9Relationship behaviors

Not serious – The child has and keeps friends their own age, and has healthy friendships with people of different ages, such as with a grandparent or younger neighbor.

Mildly serious – The child often aggravates others by arguing, teasing, bullying or other immature behaviors, and friends often avoid them.  They are quick to have temper tantrums and childish responses to stress.  Or they have no friends their age, or risky friends.

Serious – The child is frequently mean or angry to people and animals, and can be manipulative or threatening, or damage others’ property.  They have poor judgment and take dangerous risks with themselves or others.

Very serious – The child’s behavior is so aggressive verbally or physically that they are almost always overwhelming to be around.  The behaviors are repeated and deliberate, and can lead to verbal or physical violence against others or themselves.

photo1If your child’s behavior falls along the spectrum encompassing Serious to Very Serious behavior, get good mental health treatment for them now and spare them a difficult future.

Pay attention to your gut feelings.

If you’ve been searching for answers and selected this article to read, your suspicions are probably true.  Most parents have good intuition about their child.  If you’re looking for ways to “fix” or change your child… all I can say is that this approach will probably not work.  You may need to work on yourself; you may need to change how you relate to your child or picture your situation.  Regardless, seek help.

photo4Early treatment, while your troubled teenager is young, can prevent a lifetime of problems.  Find a professional who will take time to get to know your situation, and who will listen to what you have to say–a teacher, doctor, therapist, or psychiatrist.
–Margaret

Your comments are welcome.

(Tell me how I’m doing. Please rate this article above, thank you kindly.)

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Your rights as the parent of a teen with a mental disorder

Your rights as the parent of a teen with a mental disorder
7 votes

Parents have more rights than they think.

In a previous blog article on the subject of parents rights, I described how parents can be shocked to learn that their troubled teenager has the right to refuse treatment, Teen rights versus parent rights when the teen has a mental disorder.

What if your teen refuses treatment?  As you know, they usually get worse. Tragically, if your teen experiences serious symptoms of the disorder for a long period, such as in schizophrenia or bipolar disorder, their brain loses cognitive function just as in Alzheimer’s disease.  A troubled teenager doesn’t have the rational thinking to make medical decisions.

If a teenager had any other illness besides a behavioral disorder, withholding treatment would be considered child abuse and grounds for removing the child from the home.

Laws in many countries err on the side of protecting a person’s civil rights, but a teenager is likely not ready to take the responsibility that goes along with these rights. An excellent site covering laws pertaining to Special Education Law is Wrightslaw. Click on “Topics from A to Z.”

  • For safety and health reasons, you have the right to search your teen’s room and remove or lock-up risky items like drugs, weapons, razors, pornography, or anything affecting health (rotten food, unclean garments, chemicals). Be careful: this can destroy trust if done inappropriately! Inform your teen only if you find and remove unsafe items but otherwise leave everything else alone! If you call the police regarding illegal items, and if your child is charged, their criminal record can be expunged by age 18.
  • You can set any curfew time you think appropriate, and you do not have to adhere to curfew times used by law enforcement. Suggestion: compare with other parents’ curfews. Your teen will more likely follow rules that his or her peers follow.
  • You can monitor everything in your home, and on your computer and phone. You can limit cell phone services, and get GPS tracking on the phone and in the car. Prevention is more effective if your teen is informed about this, and it prevents others from taking advantage of your child, too.
  • You can report your concerns to anyone: teachers, other parents, and the local police precinct.
  • You can search for your child by calling other parents or businesses, or visiting their friends’ homes, or searching public places where your child might be.
  • You can and should call the police if your child runs away, or if your child is being harbored by someone who wants to ‘protect’ them. It is illegal to harbor runaways and those who do are subject to criminal charges.
  • You can and should notify anyone who encourages your teen to run away, or who takes your teen with them without your permission, that this is custodial interference or kidnapping and subject to criminal charges.

You have the right to be involved in treatment

“Communication between providers and family members needs to be recognized as a clinical best practice.”*

  • You have the right to contact any mental health professional directly, and provide information relevant to your child, your family (e.g. marital conflict), and your family’s needs (e.g. bullied siblings). The professional can legally receive and document this information, but may not be able to discuss it with you.
  • You have the right to communicate freely and openly with a practitioner or teacher about anything you both already know—no confidentiality exists.
  • You have the right to schedule your own appointment with a professional without your teenager, and ask for information about how to get help for yourself and your family, and what kinds of help you may need.
  • You have the right to information about your child’s diagnosis and behavioral expectations, the course of your child’s treatment, and how you should interact with your child at home.
  • You have the right to a second opinion. And you have the right to change treatment or refuse treatment based on that second opinion.
  • You have to right to participate fully in medical decisions about your child. For example, you have the right to ask a doctor to stop or change medication or treatment that is creating behavior problems or side effects, which harm your ability to manage your teen.
  • You have the right to “information about the treatment plan, the safety plan, and progress toward goals of treatment.” *

“While confidentiality is a fundamental component of a therapeutic relationship, it is not an absolute.”*

“Medical professionals can talk freely to family and friends, unless the patient objects after being notified of the intended communication. No signed authorization is necessary.”

–Susan McAndrew, Deputy Director of Health Information Privacy, U.S. Department of Health and Human Services

Teachers and mental health professionals have leeway with confidentiality.  Professionals often misunderstand the Health Information Privacy and Accountability Act (HIPAA), which defines what must be kept confidential. Many also misunderstand the Family Educational Rights and Privacy Act (FERPA) and state laws that govern confidentiality, so they tend to err on the side of confidentiality. However, the American Psychiatric Association states:

“Disclosures can sometimes be justified on the grounds that they are necessary to protect the patient. For instance, it is generally acceptable for a psychiatrist to warn a patient’s family or roommate when the patient is very depressed and has voiced suicidal thoughts”* or plans to harm others.

Professionals should provide explicit information about safety concerns: such as the warning signs of suicide; the need to adhere to medication and other treatment; an explanation of how your teen’s disorder can impair judgment; an explanation of reasons the teen must avoid substances like alcohol and drugs (including some over-the-counter drugs); and the need to remove the means for suicide, especially firearms, sharp objects, matches, chemicals, etc.

How doctors and therapists manage confidentiality

Their basic philosophy is to do what is in the best interest of their patient. For example, if the teen is in an abusive family situation or seeking care only on the condition of confidentiality, their privacy will be protected. “The default position is to maintain confidentiality unless the patient gives consent… However, [family members or friends] may need to be contacted to furnish historical information…” If the practitioner determines that the teen is (or is likely to become) harmful to him- or herself or to others, and will not consent, then they are… “justified in breaking confidentiality to the extent needed to address the safety of the patient and others.”  –The American Medical Association, 2001, “The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.”

A good professional will be honest with your teen, and tell them that they will communicate with parents based on what they already know. They will also tell your child that suicide or violence risk will always be communicated to you and/or an emergency medical service. From everyone’s perspective “It is always better to defend an inappropriate disclosure than to defend a failure to disclose with bad outcome (e.g. injury or death).”

Giving a teenager with behavioral problems the rights to make critical medical decisions is too risky!

I hope that families and mental health advocates can someday agree on how to maintain civil rights without letting a person control their future when they are not in their right mind. Until then, work with the system as best you can. I find that teachers and practitioners do their best to help families despite the restrictive civil rights and confidentiality mandates. Good luck.

How am I doing? Please rate this article, thanks.  Margaret

* Reference“The Clinician Should Maintain a Confidential Relationship With the Child or Adolescent While Developing Collaborative Relationships With Parents, Medical Providers, Other Mental Health Professionals, and Appropriate School Personnel,” developed by Jerry Gabay JD and Stewart S. Newman MD. The authors would like to acknowledge the support of the Oregon Council of Child and Adolescent Psychiatry for their support of this effort.

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Managing defiance: tips and advice

Managing defiance: tips and advice
4 votes

If you raise a defiant child or teen, this is a most important piece of advice:  take care of yourself, your primary relationships, and the rest of your family. You have a life, and your other children need nurturing.  Schedule regular times for you and the others to relieve tension and do something that takes you out of the home and brings you joy.  The time or expense is worth every bit as much as psychotherapy.

These are typical traits of defiant children.

  • They act younger than they are. Don’t expect them to mature quickly.
  • They live in the here and now, and can’t think about the past or future.  They don’t see how their actions result in a series of consequences.  They can learn sometimes, but only if it is pointed out immediately after an incident.
  • They don’t notice their effect on others.  Sometimes you can ask one of the others how they feel immediately after an incident, or you can gently report how it makes you feel.
  • Their brain is easily overloaded, and they have a hard time with changes.  And yet, you can use this overloading problem to your advantage (more below).
  • They cannot follow your reasoning, so don’t try.
  • Defiance may be a strength in their future. With mature skills, they’ll better resist negative things they’ll face in life.

 

One of the most effective things you can do is control your tone of voice.

Managing defiant children is a balancing act.  If you go too far asserting authority you can draw more resistance, especially if you become emotional.  Your defiant child is very sensitive to a tone of voice that sounds (even a tiny bit) defiant or impatient or angry.

Practice ahead of time

Before you make a request or set a boundary on your child, practice what you will say in advance.  Play the dialogue out in your head—imagine their reaction to your request or rule, and practice that neutral tone of voice.  Remind yourself that you are the authority, and that you are more resolved and persistent than they are.  Your message doesn’t have to be rational or justified.  You may get away with things like, “Because I’m the mommy (or daddy) and I say so”.

Approaches that work

Be a benevolent dictator

Since your home is not a democracy and your child does not run the household, they are not entitled to have all their needs fulfilled or opinions considered.  When they make a demand, thank them for letting you know their opinion, and explain how you will weigh their needs with those of everyone else.  Your child will find your decision completely unfair, but remind yourself that “fair” is not “equal.”   (It’s not desirable to treat everyone and every situation equally.)  Say it’s the best you can do for now.  As their accusations fly, dial back your interest, get busy with something else, and become distracted

Allow some aggression

When it’s appropriate and safe, ask your child to do more of what they’re already doing so that they turn it around and defy you by stopping the behavior. Example: your child refuses to take a direction and throws a book on the floor in anger.

Parent:  “There’s only one book on the floor. Here is another one, now throw this on the floor.”  (Child throws book down.)

“Here’s another one. Throw this down too.”  (Child throws book down.)

“And here’s another book, throw this one down, too.”  (Child becomes frustrated and angry, but stops throwing books in defiance.)

Be a marshmallow

Show no resistance, instead, listen and respond to how they feel, not what they say.  Show them you are open to genuine talk later when the stress dies down.

Teen:  “I hate you, you f- -king b- -ch!”

Parent:  “Sounds like you’re really angry.”

Teen:  “Shut up you stupid wh- -e!  You c – -t!”

Parent:  “Can you tell why me you’re angry so I can do something about it?”

Teen:  “Leave me alone f- -k face!  Stop patronizing me!”

Parent:  “OK, I hear you don’t want me to patronize you, so I won’t.  I feel this is stressful for both of us, so I’d like to take a break and maybe talk about it later.”

Call their bluff

Child:  “I’m going to run away!”

Parent:  “OK, if you do, find a way to call me, and I’ll bring you your stuff and maybe a snack.”  Then walk away.  If they do run and call you, you’ll know where they are.

Reverse psychology

Parent:  “Oh my God, I can’t believe what you’ve done to your hair, that’s horrible!  What are people going to think?  That’s worse than tattoos.  You have to stop this nonsense!”

(One mother used this technique to get her daughter to stop her plans to make a homemade tattoo on her face.  After all, hair grows out, but facial tattoos can be forever.)

Overload their brain circuits

Give your child or teen multiple instructions quickly, and include things they do and don’t want to do.  It becomes too much work for them to sort out what to defy.

Parent:  “Keep up the yelling and close the door on your way out.  And be sure to get louder out there so all the neighbors can hear.  Dinner is at 5:30.”

(What happens?  The door is slammed maybe, but your child is home at 5:30 for dinner.)

Actively ignore

This works best with children 2 through 12.  They try to get a reaction by annoying you or threatening to do something you don’t want them to do.  Stay in the vicinity but don’t respond, look away, and act like you can’t hear them.  Go into another room or outside, for example, and the annoying child will follow you to continue to get your attention with annoying behavior.  If they flip the lights on and off, or ring the doorbell repeatedly, or turn up the volume too loud, maybe you can switch a circuit breaker off and walk away… or if driving, you can pull over, stop the car, and get out and wait.  This article can help with other ideas.  Defying ODD: What it is and ways to manage.

Mix it up

  • Be unpredictable.  Give a reward sometimes but not all the time, and your child will keep trying the good behavior to get the reward.
  • Instead of a consequence, occasionally use bribes to stop a behavior.
  • Allow them to do something they like to do, but within limits of boundaries.
  •  Choose your battles; let your child win unimportant disagreements.
  • Be sneaky on occasion if  (or frankly manipulative) if nothing is working.  For example: suggest you’re considering a very serious consequence that you don’t intend to follow through on.

Have realistic expectations

It’s easy to get stuck in rut—it happens to everyone—but your child is stuck too.  Remember,  it’s not the child’s fault and it’s not your fault.  Your child may not go through life the same as others and may always have problems, but your job is to help them learn from their mistakes the best you can.  This may not happen for many years.  If your child’s condition is serious, they may face serious problems because of their disability, but you’ll know you’ll have honored them, lived your values, and loved unconditionally.

It is heroic to stick it out with your defiant child or teen when you don’t see progress.

Hope

  • They have the ability to do better.
  • With treatment, children improve (e.g. therapy, exercise, medication…).
  • Things usually work out.
  • Help is out there.

–Margaret

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