Tag: oppositional defiant disorder

Therapy types explained: DBT, CBT, CPS, and others

Therapy types explained: DBT, CBT, CPS, and others

The fantastic news about the brain is that it can heal itself by talking with someone! Ample evidence backs this up.

The therapist or psychologist who works with your child or teen will use a type of therapy or “modality” based on their symptoms or diagnosis, because some work better for mood disorders, some work better for defiant children, some work better for borderlines, and so forth. (In thought disorders like autism and schizophrenia, talk therapy has limits. Those on the autism spectrum need specialized interactions due to their processing issues. Those on the schizophreniform spectrum need medication to think logically before starting

Therapy models. Each type of therapy follows a model, and five are covered in this article. Your child’s therapist must be trained and practiced in any model they use. Why? It’s a matter of quality control. A therapist who has fidelity to a model (adheres to protocol) will help the most people most of the time, because that model has data to prove that the majority will benefit–the ones in the center section of the Bell Curve. (Therapists include psychiatrists, psychologists, and psychotherapists with MSW (Masters in Social Work), LCSW (Licensed Clinical Social Worker) and other licensure.)

Therapy models

CBT – cognitive behavioral therapy
CBT works when the child can examine their own feelings and make sense of them—the “cognitive” part. They learn to understand what affects them and why. The therapist will guide your child to create a list of options for themselves for when they face the next stressful situation that pops up in their lives. CBT helps a person think their way out of the confusion and have plans in place for appropriate actions. It works for mood disorders and anxiety, and some thought disorders if person has ‘insight’ (able to notice when they are behaving or thinking irrationally). CBT is one of the most widely used therapeutic models because it works for people who are relatively stable but enduring a difficult life situation (divorce, medical illness, job loss, and other big stressors).

DBT – dialectical behavioral therapy
DBT is unusual in that it can help anyone for any reason! The term “dialectical” describes how a patient learns to hold two opposing truths in their mind and respond effectively to the discomfort and emotions this causes. DBT is the one therapy model that can work for people with borderline personality disorder, who are considered the hardest to treat. It also helps those with mood dysregulation, those who’ve thought about or attempted suicide, or those with uncontrollable and negative responses to the world, such as oppositional defiant disorder. DBT relies less on personal self-examination and analysis, and instead concentrates on self calming, tolerating stress without overreacting, accurately perceiving the nature of a conflict, and communicating with others appropriately. Anyone can benefit from DBT. Notice how commonly people hear bad news and immediately expect the worst, then act to address the worst possible outcome? Does your child do this, only to extremes?

EMDR – eye movement desensitization and reprocessing
The goal of EMDR therapy is to help a person process extremely distressing memories of trauma and mitigate their torturous subconscious influence so children and adults can adapt and cope when memories are triggered in the future. EMDR is used for people with PTSD (physical, sexual, or emotional abuse) and other traumas such as from war, accidents, and major disasters. The therapy process uses rhythmic stimuli as a distraction during the precise moments when the person relives the traumatic memory—eye movement back and forth (by following a swinging object or a therapist’s hand), clapping, or listening to tones switching from ear to ear through headphones. The person does not have to talk about the horrible memory, so EMDR is less stressful—so important for a trauma survivor! EMDR works but there are no acceptable explanations. It is based on a belief that the memory and associated stimuli of the event must be processed to remove it from “an isolated memory network” where it creates havoc.

Parents as therapists

There are two proven models of therapy that are taught to parents to practice with their children in the home. Like the other models, they don’t work for every child, but they work for most children with a certain range of behaviors, rages, resistance, and physical violence, which can be caused by ODD, ADHD, and depression/bipolar disorders.

CPS – collaborative problem solving
CPS can be learned by anyone to manage an intensely frustrated child who goes into uncontrollable fits or tantrums, and the parent can do nothing to calm them down. The fits may last hours, and must run out of steam on their own. Afterwards, the child is often remorseful. Why? Their brain is “chronically inflexible” and has difficulty with the unexpected, switching from one situation to another or one plan to another. Using CPS, a parent doesn’t enforce rules per se, but negotiates with child so that they together come up with a win-win solution. This is very counterintuitive! The parent does not give away their authority, but offers the child an acceptable choice. For example, if a child can’t get a red jacket because there aren’t any in their size, and they must have red (!), the parent asks the child if they want to order one and wait 2 weeks, or if they will accept another color. This seems fair to the child because they have a say, and much easier on the parent because the child accepts the outcome they’ve chosen.

PMT – parent management training
PMT refers to a proven intensive educational program for parents to teach them skills for managing extremely difficult children, especially those with ODD. PMT helps parents assert consistency and predictability at home and in school, and promote positive social behavior in their child. The parents are also trained to change their own behavior towards their child, and taught how to analyze different home/school situations, “then apply moment-to-moment positive reinforcement or punishment” (called interventions) based on what is happening. The punishments are humane, such as taking time outs. It is hard on the parents, but works for children with serious behavior problems in addition to ODD: Conduct disorder, ADHD, and autism spectrum disorders.

What makes a good therapist? Because multiple models are out there, a really skilled therapist will figure out which model your child needs once they get to know them, and they will apply parts of different models depending on your child’s individual challenges. That same skilled therapist will also be a cheerleader for your child, helping them feel good about themselves (and you), helping them discover their talents, and helping them to stay committed to their need for self-care. This is the very definition of a good therapist! Therapy is hard to take for anyone, but your child will trust a good therapist if they feel they have their best interests. Chemistry is important. If your child doesn’t like the therapist or make progress, it’s worth spending the time to find someone else who’s a better match. If the therapist has professional ethics; they will recognize they are not a fit and recommend someone else.

I know of a 10-year old child whose therapist dragged out appointments for a year with zero progress or results. From the start, the child didn’t like her and simply refused to talk with her. And this child, now 11, refuses any therapy because “it’s boring and a waste of time.” What an unfortunate consequence!

How you know you have a good therapist. A good therapist will be able to discover something valuable that brings light on your child’s situation after the very first session. They should ask you for background information about your child, and listen to you when you talk about recent problematic situations. They cannot talk to you about your child’s therapy, but they can encourage you to partner with them, and should recognize your need (your family’s need) for your child to function as normally as possible. You can ask to have therapy together with your child if its appropriate. If the therapist can’t connect meaningfully with your child after a few weeks, ask them about this. If you have any doubts about the therapist, share them, and expect to have a thoughtful, respectful explanation.

Which therapy is best for your child?

Seek a therapy provider with knowledge of all of them, and with experience treating children and teens. Ask about a specialty when you make the initial contact, and ask about a model you think fits your child’s behaviors (based on their descriptions). You can get a one-time assessment from a therapist for an opinion on which model to use. The best way to find a good therapist is through personal referrals: your child’s doctor or psychiatrist, support groups, school counselors, and other parents.

Defying ODD: what it is, and ways to manage.

Defying ODD: what it is, and ways to manage.

Not only is ODD exhausting, but parents must find the energy and doggedness to be consistent, and the compassion and forgiveness to be nurturing.

ODD is caused by abnormal electrical activity in the brain, it is not in the character or ‘soul’ of your child or teen, and not something they can control.  If your child could do better on their own, they would.  You are the one who can make the most difference.

If you think your child or teen’s defiance is oppositional defiant disorder, you have practical ways to manage your child’s exasperating condition.  This information comes from psychiatric, psychological, and child behavior resources– information to help you work effectively with mental health providers or teachers.  You’ll need to ask them focused questions to learn everything they know about ODD.  Professionals pay better attention to knowledgeable parents (which shouldn’t be the case, all parents deserve attention).  Go in armed with knowledge.

This is what ODD looks like.  The pinkish curving region in the center of the 3-D brain image below represents hyper-charged electrical activity in a 13-year-old boy with severe oppositional defiant disorder.  This feature is typical of ODD, but also typical in individuals with obsessive compulsive disorder (OCD), “Road Rage,” pathological gambling, chronic pain, and severe PMS.

The name of this region is anterior cingulate gyrus (ACG), and scientists believe this area is responsible for enabling a person to shift attention and think flexibly, traits which are deficient in ODD kids.  It is also the brain region known to regulate emotions.  Children with a hyper-charged ACG have “a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which 4 or more of the following are present:

  • Often loses temper
  • Often argues with adults.
  • Often actively defies or refuses to comply with adults’ requests or rules.
  • Often deliberately annoys people.
  • Often blames others for his or her mistakes or misbehavior.
  • Is often touchy or easily annoyed by others.
  • Is often angry and resentful.
  • Is often spiteful and vindictive.” 

–From the “Diagnostic and Statistical Manual of Mental Disorders, 4th Edition,” published by the American Psychiatric Association, 2000.

There are two different medication approaches to ODD:

  • treat it as a form of attention deficit disorder;
  • treat it as form of depression and obsessive-compulsive disorder.

The attention deficit approach may use Straterra (chemical name is atomoxetine), Ritalin (methylphenidate), Risperdal or risperidone (for patients with low IQ), and Depakote or divalproex (a mood stabilizer).  This is not a complete list because new compounds may come into the market.

The depression & obsessive-compulsive approach may use serotonin-based antidepressants such as Prozac (fluoxetine), and Anafranil or clomipramine (used to treat OCD).  Again, this is not a complete list.

Oppositional defiant disorder often includes symptoms from other disorders, so you may be coping with more than defiance.  Below are common disorders that combine with ODD:

  • 50-65% of these children also have ADD or ADHD
  • 35% of these children develop some form of depressive disorder
  • 20% have some form of mood disorder, such as bipolar disorder or anxiety
  • 15% develop some form of personality disorder
  • Many of these children have learning disorders

Anthony Kane, MD 

Other medical conditions that can cause disruptive behavior like ODD:

  1. Neurological disorders from brain injuries, left temporal lobe seizures (these do not cause convulsions, no one can tell these are happening), tumors, and vascular abnormalities
  2. Endocrine system problems such as a hyperactive thyroid
  3. Infections such as encephalitis and post-encephalitis syndromes
  4. Inability to regulate sugar, rapid increases and decreases of blood sugar
  5. Systemic lupus erythematosus, Wilson’s disease
  6. Side-effects of prescription medications:  Corticosteroids (anti-inflammatory and arthritis drugs such as Prednisone);  Beta-agonists (asthma drugs such as Advair and Symbicort)

–From Peters and Josephson.  Psychiatric Times, 2009.

ODD is a disability.  It isn’t easy to manage, but you can do it.  Your child may need multiple medications and a large variety of approaches to therapy and behavior modification.  You will need patience as his or her teachers, doctors, or specialists try different approaches until they discover one that improves your child’s behavior, so hang in there!

Some good news, if your child has these traits, it will be easier to improve or overcome ODD behaviors:

  • A normal IQ
  • A first-born child
  • An affectionate temperament
  • Positive interactions with friends their age
  • Nurturing parents who can consistently set clear behavioral limits

–From the Journal of American Academic Child and Adolescent Psychiatry, 2002.  Author J.D. Burke.

People’s natural instincts of parenting do not work with an ODD kid.  They need completely different techniques than normal children. 

How to reduce ODD behaviors

Shield yourself.

First get a shield, then prepare yourself for the intensity of parenting a defiant kid because you are about to run a marathon.  Get enough sleep, maintain your other important relationships (spouse or partner, children, friends), schedule breaks or getaways, and guard your physical and emotional health.  Don’t expect quick results with these techniques; it may take weeks or months… years.

Tips from professionals that may work for you:

Parent Management Training – PMT refers to intensive educational programs that are “evidenced based,” proven to help parents gain the skills they need for extremely difficult children, especially those with ODD.  These programs are intensive, but substantiated interventions in child mental health.  PMTs help parents assert consistency and predictability, and promote pro-social behavior in their child.  A good explanation can be found at the Encyclopedia of Mental Disorders.  Examples include:  the Total Transformation and the Incredible Years.

Find something positive to do together.  Your child has normal needs for closeness and appreciation and joy.  Ask your child about their interests, and if their ideas don’t work for you, try new activities until one brings about a good chemistry between you and your child.

Praise is one of the most powerful tools for managing disruptive behavior.  Make an effort to inject as much positive energy into your relationship with your child or teen.  It’s likely that this relationship has been close to 100% negative, yes?   Caution: don’t expect thanks or joy from your child once they’re praised; it’s not about you.

Set limits – “Consistent limit setting and predictable responses from parents help give children a sense of stability and security.  Children and teens who feel a sense of security regarding the limits of their environment have less need to constantly test it.”  (Webster-Stratton and Hancock)

Active ignoring – This works for best with children between the ages of 2 and 12.  It involves purposefully withdrawing your attention away from your child when they are misbehaving, such as in a temper tantrum, or when whining or sulking, or when making continuous demands or loud complaints, etc.  Pretend you don’t care and even turn your back if possible.  Give attention only after the behavior is over.

Make the behavior uncomfortable for the child/teen.

  • Example:  If your kid swears, test them, “C’mon, you can do better than that, be creative, I’ve heard all those things before.”  They can get frustrated when they aren’t getting the reaction they want from you, and give up.
  • Another example:  Your teen refuses to get out of bed for school.  Don’t nag or repeat, repeat, repeat.  Remove the bed covers and set them far enough away that your child has to get out of bed to retrieve them.  (“Managing Resistance,” John W. Maag, jmaag1@unl.edu)

Give multiple instructions at once, where at least one of the instructions is what they want to do, and one is what you want them to do.  “Close the door while you’re yelling at your sister and don’t forget the light.”  Your child will be overloaded as they try to figure out which thing they’re supposed to defy.  Kids tend to get flustered by the mental effort and comply without knowing they’re doing it. (from “Managing Resistance,” see above)

Reverse psychology:  Yes, this works, and it’s OK when important.  Example:  your child is bouncing on the furniture.  You turn on music and say “hey, try this, see if you can bounce to the beat, it’s harder to do on the floor.”  This is a good kind of manipulation.

Unexpected rewards – Occasionally reward appropriate behavior with something they like.  They are more likely to do a desired behavior if they expect something they want and aren’t sure when it will be offered.

“Why should I have to do this when it’s my kid’s responsibility to behave?”

It’s your responsibility as a parent to do what you can to help your child be successful.  ODD is a genuine disability that negatively affects their life and future.  I’ve seen highly intelligent ODD kids experience academic failure or enough suspensions and expulsions to hold them back a grade.  This is a can’t-win-for-losing path sucks, doesn’t it?

Warning, once you start consistent enforcement, things get worse at first – Defiant behavior will increase once your family system is changing.  This as a good sign—you are regaining your authority!  Your child’s backlash is a common human psychological response, and it’s called an “extinction burst,”  see diagram below.  As parents change their approach to handling inappropriate behavior, the child becomes more defiant to test their resolve.  View this as predictable and plan ahead.  It won’t last, and they will eventually comply with this one rule.  They then find another rule to defy and ramp up their defiance.  As you enforce it, they back off again, and the pattern continues until it’s just not worth it to defy these particular rules anymore.

 

–From “Behavioral Interventions for Children with ADHD,” by Daniel T. Moore, Ph.D., © 2001, http://www.yourfamilyclinic.com/shareware/addbehavior.html .  The author requests a $2 donation through PayPal to distribute his article or receive printed copies.


Tips for effective parenting of an ODD child through adulthood

Don’t treat your home like a democracy, where everything must be fair and equal.  You must be the supreme ruler, the benevolent dictator.  Your child does not have an equal say in how things are done.  Parents must keep their authority and rightful power in the household, and tell their ODD child that they make the important decisions, plus, the decisions may not always seem fair. Tell them you’ll listen to what they have to say but make no promises. Once you’ve made a decision, avoid explaining your reasons when they challenge you. This helps you keep their power, and it limits endless arguments and accusations. As your child ages into adulthood, you must still hang on to your power. The adult child will continue to require limits, and limits will still need enforcement. To a parent, it will feel as if you’re treating your adult offspring as a child. YOU ARE and you should be, and this is the interesting part: they won’t notice.

Don’t blame or belittle your child-–this goes for all children–but a difficult child can bring out the worst in an exhausted parent. It’s easy to think they’re being bad on purpose because they’ll act like it, and show amusement when they’re bad or belittle you. Keep in mind that ODD is no one’s fault, and your child would not choose to have ODD if they understood what it meant.

Don’t ignore your child’s unique needs that have nothing to do with ODD.  They may face bullying at school, lack of sleep, stress from a chaotic home, or other challenges like any other child.

Always enforce rule breaking as immediately after the fact as possible.  Why:  If enforcement comes later or only occasionally, the child does not connect the broken rule with the punishment. Or, they believe they can still get away with breaking a rule and then talk their way out of consequences later.

Don’t let your stress turn into anger directed at your child.

  • They can use this against you by teasing or baiting to get you angry again!
  • You’ll be modeling that anger is an OK response to stress.

Take care of your emotional wellbeing. Check in with yourself if you feel you are losing control. All parents with troubled children need to work extra hard at maintaining a level head. It’s a good skill to have anyway.

Avoid justifying your rules or offering explanations. Children with ODD are not able to reason when they turn defiant. They will only resist harder and use your words to argue more with you. Even if they can understanding your reasoning in a calm moment, this will vanish once they become defiant again.  (What’s interesting is I’ve observed parents trying to reason with young children(4 or 5), too young to be reasonable in the first place, or with young adults (early 20’s) who have a long track record of being unreasonable.

Don’t interpret everything as ODD-defiance.  Some rebelliousness is normal for children, especially if parents are over controlling.

Don’t keep trying the same things that still don’t work.  Like making excuses; like screaming.  (Don’t be embarrassed; we’ve all done this.)

Don’t jump to conclusions that demonize the child.  It hurts you as much as it hurts them. I often hear parents say:  “Why does he keep doing this?, or, “Why doesn’t she stop after I’ve told her not to, over and over again.”  Then they answer their own questions:  “It’s because he always wants his way,” or, “She’s doing this to get back at me.”  As they tell their story, I hear them taking things personally:  “He does this just to make me mad;” “She manipulates the situation because she wants more (something) and I won’t give it to her.”

Good luck with your defiant ODD child.   Hang in there.  I WISH YOU THE BEST!

–Margaret

How am I doing?  Please comment.


 

Parent to Parent Guidance

Parent to Parent Guidance

Margaret Puckette is a Certified Parent Support Provider, and assists parents on how to effectively raise their troubled child. She believes parents need realistic practical guidance for family life and school, not just information about disorders. Margaret has mentored families for over 20 years. She is an author & speaker, and knows from personal experience there is reason for hope.

You Can Handle This.

You Can Handle This.

You are not alone. It's no one's fault. Behavior disorders are disabilities! Troubled children need a very different parenting approach than 'normal' kids.

Care for yourself first, then set new goals:
1. Physical and emotional safety for all
2. Acceptance of the way things are
3. Family balance, meet the needs of all
4. One step at a time, one day at a time

Practical Guide for Parents

Practical Guide for Parents

A guide with practical steps for reducing stress at home and successfully raising a troubled child. You use the same proven techniques as mental health and other professionals. It starts by taking care of your wellbeing first, then taking an entirely different approach to parenting.
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