oppositional defiant disorder -...

Oppositional Defiant Disorder

EDUA 2800 – A13


(ODD)

Nicole Allan Lacey Ginter DeJongColby GrypiukDanny NguyenBrittany Thomson

3/3/2011


WHAT IS OPPOSITIONAL DEFIANT DISORDER?Clinical / Diagnosis Definition

ODD is a disruptive behaviour disorder:

Oppositional defiant disorder (ODD) is a disorder found primarily in children and adolescents.

It is characterized by negative, disobedient, or defiant behaviour that is worse than the normal "testing" behaviour most children display from time to time.

Most children go through periods of being difficult, particularly during the period from 18 months to three years, and later during adolescence. These difficult periods are part of the normal developmental process.

Children who have ODD are… …often disobedient. They are easily angered and may seem to be angry much of the time. Very young children with the disorder will throw temper tantrums that last for 30 minutes or longer, over seemingly trivial matters.

…often starts arguments and will not give up. Winning the argument seems to be very important to a child with this disorder. Even if the youth knows that he or she will lose a privilege or otherwise be punished for continuing the tantrum or argument, he or she is unable to stop. Attempting to reason with such a child often backfires because the child perceives rational discussion as a continuation of the argument.

… do not perceive themselves as being argumentative or difficult. It is usual for

such children to blame all their problems on others. Such children can also be perfectionists and have a strong sense of justice regarding violations of what they consider correct behaviour. They are impatient and intolerant of others. They are more likely to argue verbally with other children than to get into physical fights.

Causes The exact cause of ODD is not

known. It is believed that a combination of the following that may contribute to the condition:

(1) Biological factors: Some studies suggest that defects in

or injuries to certain areas of the brain can lead to serious behavioural problems in children. In addition, ODD has been linked to abnormal amounts of special chemicals in the brain called neurotransmitters. Neurotransmitters help nerve cells in the brain communicate with each other. If these chemicals are out of balance or not working properly, messages may not make it through the brain correctly, leading to symptoms of ODD, and other mental illnesses.

Further, many children and teens with ODD also have other mental illnesses, such as ADHD, learning disorders, depression, or an anxiety disorder, which may contribute to their behaviour problems. (2) Genetic factors:

Many children and teens with ODD have close family members with mental illnesses, including mood disorders, anxiety disorders, and personality disorders. This suggests that a vulnerability to develop ODD may be inherited. This pattern may, however, reflect behaviour learned from previous generations rather than the effects of a gene or genes for the disorder.


(3) Environmental factors: Factors such as a dysfunctional

family life, a family history of mental illnesses and/or substance abuse and inconsistent discipline by parents may contribute to the development of behaviour disorders.

Signs/Symptoms:According to the DSM-IV-TR, a diagnosis of ODD may be given to children who meet the following criteria, provided the behaviour occurs more frequently than usual compared to children of the same age and developmental level. A pattern of negative, hostile, and defiant behaviour lasting at least six months, during which four (or more) of the following are present. The child:

- often loses his or her temper - frequently argues - often disregards adults' requests or

rules - deliberately tries to provoke people - frequently blames others for his or her

mistakes or misbehaviour - is often easily irritated by others - is often angry and resentful - is often spiteful

In order to make the diagnosis of oppositional defiant disorder, the behavioural disturbances must cause significant impairment in the child's social, academic or occupational functioning, and the behaviours must not occur exclusively during the course of a psychotic or mood disorder.

Stats: 40% of children with ADHD also

meet diagnostic criteria for ODD. Children with ODD were twice as

likely to have severe major

depression or bipolar disorder. Approximately 1/3 of children with

ODD develop Conduct Disorder (CD), 40% of whom will develop antisocial personality disorder in adulthood.

Conduct Disorder is a severe, chronic disorder, driven by anti-social behaviour,

(Hamilton & Armando, 2008)

Prevalence: More common in preschool boys

than girls Behaviours in girls become more

evident after puberty Onset of ODD is usually gradual Evident before 8 years of age and no

later than early adolescence

0%

10%

20%

30%

40%

50%

60%

70%

80%

Prevalence of ODD in the U.S.

Prevalence

*Source: U.S. Census Bureau, 2004


ODD becomes less prevalent as people age, with the first bar of the graph representing 15-59 year olds at about 40% and significantly less at about 8% for people over 75. But ODD in childhood can lead to other complications and disorders in adulthood. The number of males with ODD is nearly double that of females. Data is inconsistent when it comes to gender. Some researchers propose that different criteria be used with girls, who tend to exhibit aggression more covertly. Girls may use more verbal, rather than physical aggression, often excluding others or spreading rumours about another child.

This is also consistent in Australia, according to a study that looked at the hospitalization rates for children aged 1-14. ODD occurred among the most frequent disorders at 16% accounting for hospitalization for mental health and behavioural disorders.

The Brain: People with ODD may produce an unusually high level of the neurotransmitter nor-adrenaline. This is the neurotransmitter of arousal, high energy, and urgency, which influences us immensely, especially during fight-or flight response. It is released in the locus ceruleus which is in the midbrain. Under these circumstances, even a small stimulus will create unusually strong arousal. Also, the amygdala is affected in people with ODD, which is a small structure in the temporal lobe that regulates fear, since individuals with ODD often have little, if any, fear of consequences.

Pharmacologic Treatment: There has been very little research on the use of medication to treat ODD.

Several studies have found that medications used in the treatment of ADHD, are effective in the treatment of ADHD with co-existing ODD. Although, studies have not shown that these stimulants reduce ODD symptoms when ADHD is not present. Some of the most common medications that are used to treat ADHD with co-existing ODD are:

Methylphenidate (Ritalin) Atomoxetine (Strattera) Amphetomine (Adderall)

These medications can assist in diminishing the problematic behaviours until the child and the systems around him/her develop the skills to cope with the oppositional behaviours.

There is also the issue of self-medication in adolescents and older adults especially with amphetamines, which could turn into a very serious problem. Amphetamine dependence occurs when an individual uses one or more of the amphetamine substances in a maladaptive way resulting in at least three of the following symptoms:

a need for increased amounts of amphetamines to achieve the desired subjective effect (tolerance)

the presence of withdrawal symptoms such as depression, fatigue, insomnia or hypersomnia, increased appetite, or agitation; using amphetamines in larger amounts or for longer duration

a persistent, unsuccessful attempt to control use of the substance

increased amount of time spent using or obtaining amphetamines

giving up important activities in


deference to the use of amphetamines

continued amphetamine use despite related physical, emotional, occupational, legal, or relational difficulties.

In 1997, there were more than 50,000 hospital admissions in the US for treatment of methamphetamine abuse or its complications, accounting for almost 4% of all treatment admissions.

Non-Pharmacologic Treatment: There are many different methods of non-pharmacologic treatment that are currently being used to treat individuals with ODD. The following treatment strategies are focussed on treatment outside of the classroom. Research supports that a combination of non-pharmacological treatments is the most effective in treating individuals with ODD. Studies have demonstrated that parent training is an effective means of reducing disruptive behaviour. Parents often see their child’s behaviour as deliberate and under the child’s control, or that they are intentionally trying to hurt them. The difficult behaviour and social disruption caused by children with ODD can have adverse effects on the mental health of their parents. Parent training teaches parents to be more positive and less harsh in their discipline style. This type of training is more effective when both the parents and the child are involved. Play therapy is supported for children age 12 and below. The basic skills of child-centred play therapy lend themselves to creating an atmosphere that encourages the development of necessary coping skills within safe boundaries. Behaviour modification may help

manage the behaviour of a child with ODD. It is extremely important to remain consistent and have mutually agreed upon rewards and punishments. The rewards should not be money or material things, but rather privileges or activities that you know the child enjoys. Using a mix of negative and positive reinforcement is effective. A typical positive reinforcer, for example, might be a later bedtime on the weekend, while a typical negative reinforcer might be revoking TV privileges. Although there are no individual interventions that are presently documented, relationship-based interventions which include cognitive-behavioural therapy and supportive individual work, have shown positive effects. It is likely that the older the child with ODD is, the more challenging the relationship is to develop, therefore early intervention is crucial. Once a relationship is established, infusion of problem solving and social skills training can occur, although modeling of pro-social behaviours is occurring all along the relationship-building process. There are also group intervention strategies that include anger management training, stress inoculation training, problem-solving training, and group assertiveness training. It is important to have a support team when treating a child with ODD. This team could consist of mental health workers, social workers, Medical Dr’s, parents, teachers, etc. Working together is much more effective, and communication between the support team is vital. All of the child’s caregivers (e.g. grandparents, babysitters, siblings, etc) need to understand ODD as well as the treatment plan, in order for the individual with ODD to gain the greatest benefits from these treatments.

The best way to treat a child with


ODD in and out of the classroom include behaviour management techniques, using a consistent approach to discipline and following through with positive reinforcement of appropriate behaviours. Be fair but be firm, give respect to get respect.

Develop consistent behaviour expectations.

Communicate with parents so that strategies are consistent at home and school.

Apply established consequences immediately, fairly and consistently.

Establish a quiet cool off area. Teach self-talk to relieve stress and

anxiety. Provide a positive and encouraging

classroom environment. Give praise for appropriate

behaviour and always provide timely feedback.

Provide a 'cooling down' area/time out.

Avoid confrontation and power struggles

Use Behaviour Contracts

Of course, the treatment that an individual with ODD receives is dependent on the area that the individual lives, and how accessible the treatment is. For example, if

an individual lives in a rural town, they may not have access to weekly appointments with a psychologist, psychiatrist, or counsellor.

Strategies and Interventions

Dr. Lorraine Fox, in her article "Teachers or Taunters: The Dilemma of True Discipline," spoke of how parents and youth care workers come to her seminars looking for a "bag of tricks," techniques and strategies they can employ with difficult youth that will de-escalate the situation and cause the child to display proper behaviour. There are two inherent weaknesses in using that approach. First, children are creative and their behaviour will not always follow a predictable formula or pattern. Second, if someone learns a particular intervention and it does not work, then what?

Ideally, the person doing the intervention should evaluate each situation with each child based on the needs of the moment. He should know what his ultimate goal is in a given situation, and think of an intervention that will be suitable for the child and the setting. It takes time to develop this, but in the end it means never getting stuck.


GENERAL STRATEGIES AND PRINCIPLES FOR INTERVENING WITH ODD

Below are some strategies and principles to keep in mind when intervening with a youth displaying oppositional behaviour. Remember, these can also be effective with any student, not just the ODD ones.

Avoid power struggles. ODD children find energy in the argument.

Avoid verbal exchanges. Oppositional children interpret someone defending his position as an invitation to continue the argument.

Do not take it personal; do not make it personal. Focus on the behaviour and attack the problem, not the student.

Pick your battles. Target only a few important behaviours rather than try to confront or fix everything.

Avoid making things worse. Avoid making comments or bringing up situations that may be a source of argument for the student. This may include sarcasm, pointing out faults, and saying things that will cause hurt or anger in the child. The goal is to de-escalate the situation, not stir things up.

Disengage from the argument cycle. ODD children are good at hooking someone into the argument. When this happens, a

person must disengage himself. Simply state the rule or agreement that student did not follow, give a logical consequence, and then give the child time to comply. Use words like "nevertheless" and "regardless" to interrupt the verbal cycle. It is not always necessary to have the last word.

If a person finds himself getting frustrated or angry, he should take a personal timeout. Not only will he give himself a chance to regroup, but he will be a model for the child.

Establish a rapport with the student. This helps to create a connection with the child, and produces interactions that are not always negative or about poor behaviour. A teacher can point out positive attributes in the student or discover things he is good at.

Timeouts are an effective intervention when dealing with students who are upset or non-compliant. Here are some procedures that should be taken into consideration when timeouts are applied:

When they will be used. The student needs to know which behaviours would warrant timeouts (or any consequence, for that matter) and the procedures of how they will be carried out. They are especially effective when the student needs to calm down.

Where they will happen. A timeout can be taken anywhere; at the student's desk (put his head down onto his arms), or a designated spot in the room, a special chair, in a different part of the school. The length of the timeout.


Brief timeouts can be just as effective as long timeouts. The important thing is that the student is separated from the reinforcing environment. One rule of thumb is a minute for every year of the child's age. No timeout should last longer than 15 minutes; the goal is to have the student regain his self-control and rejoin the class, not to be "gone."

How it should end. Some requirements of release from the timeout are the completion of the required time and appropriate behaviour while on timeout. If the student is still not willing to alter his behaviour or is still in an escalated state, alternate interventions will have to be employed.

Post Intervention Debriefing TipsCommon post-timeout behaviours include being physically and emotionally drained, passivity, calmness, apologetic, remorse or embarrassment. Here are some tips for debriefing:

encourage the student if they are down ("We can solve this problem.") focus on helping each other (try to use "we," not "I.") remind the student that he is safe. allow the student to put the behaviour and anger behind them acknowledge feelings give the student credit for small victories review the rules before returning to the classroom do not talk about consequences (that should be done later when emotions are lower.) do not use the opportunity to get in one last shot


ODD IN THE CLASSROOMTeaching Strategies for Children with Oppositional Disorder in the Classroom

It can become very difficult to deal with a child when they are being oppositional, so the focus should be on trying to prevent this from happening.Start by identifying types of activities for the child that are likely to cause frustration and help them to develop coping mechanisms for it.

When Choosing Instruction: Carefully choose content and

instructional techniques you want to use in the classroom.

Make the lesson as interesting, engaging, and interactive as possible.

Make sure that the Student with ODD in not left out of anything and that they are actively engaged in the activities.

Posting a daily schedule can help them as well and let them know of schedule changes in advance. It helps provide structure for their day. Maximize the performance of low-performing students through the use of individualized instruction, cues, prompting, breaking down of academic tasks, debriefing, coaching, and providing positive incentives.

Teach social skills including anger management, conflict resolution strategies, and how to be assertive in an appropriate manner.

Classroom Structure: Limit the amount of downtime you have

in your class as well as avoiding long

transition times. Students with ODD are more successful when they are kept busy.

Avoid conflict by ensuring that academic work is on the student’s instructional level, that it is not too difficult, and not too easy. When work is too hard, students become frustrated. When it is too easy, they become bored.

You can blend non-desirable academic tasks with student-chosen rewards for compliant behaviour.

Ensure that positive peer social interactions do in fact occur. Do not let the student get left standing without a group when everyone else has one.

Structure lessons so that the child is required to positively work in peer groups, allowing the child a chance to use his or her developing social skills.

Use social stories and social skill lessons to ensure systematic instruction of appropriate anger management and conflict resolution skills. Role-play may work well with children with and without the disorder.

Expectations: Clearly establish behavioural

expectations. (very important for students with ODD) Start with 2 or 3, and keep a chart to monitor the progress of the student. Have the student state them at the beginning of the day; an example would be “I will follow directions.”

Give two choices when decisions are needed. State them briefly and clearly.

Praise/Positive Reinforcement: These students may not act as though

they care about what others think. Praise can be used effectively if given at the appropriate times. If you are


establishing expectations for the child rewarding them when they are following though on those is important. Making eye contact and smiling, or telling the student they did a good job can often go a long way, even when sometimes they may act as though it does not matter.

Treat students with respect even when you are disciplining them. Treat them as though they were the student that you wish them to become.

Avoid issues that will cause an argument. Only bring things like that up when they are calm and instead focus on more positive things at other times.

Consequences: Consequences are as important as

praise. I student needs to understand before they engage in oppositional behaviour that there will be consequences when they do. They need to be something that the child considers to punishment. Get to know the child so that you can choose a punishment that works for them. Punishment for one child is often reward for another. It is also important to be consistent with using the consequence so that they do not see that they can get away with their behaviour sometimes.

Avoid Power Struggles: Pick your battles. This might mean allowing a student to

rewrite and assignment or test to prove they know the material, think about your priorities.

If you need to point out something negative to the student do it in private if possible, keeping your voice low and speaking softly and slowly

Rules of Thumb Indirect or earshot praise, overhearing

Reduce the number of words you are using when around them, say and show what you mean just once, don’t explain further. Student will approach you if they need further help.

Personal time out if you think what you are saying will make the conflict worse. Good for you to cool off and a good model for them to follow.

Problems with Instructional Environments: Physical Discomfort - become restless

when… Temperature, too hot or too cold. Bad lighting Unsuitable seating or workspaces. Ask students about these things. Make

corrections.

Tedium - students will fidget when… When instructional activity requires

continued close attn. Especially when topic is not appealing Break it up into shorter segments Add something that increases interest

level

Meaninglessness - will grow restless when…

They have to work on topics they do not understand/comprehend

They see no purpose in the work. Make topics meaningful See that they understand and see that it

is relevant and important to their lives

Lack of Stimulation - Students take no interest in the lesson when…

The topic and learning environment do not provide anything attractive or stimulating.


Get to know your student so that you can select topics and activities that they are interested in.

It will not always be possible so you can also include elements that students have been known to enjoy; novelty, mystery, role-playing, competition, group work, or movement.

Conditions that reside in teachers and other school personnel: Poor habits People in schools have acquired

counterproductive ways of dealing with students. (Use bad language or speaking in sarcastic manner.

Make sure that you monitor yourself to see if this could be you.

Unfamiliar with better techniques Some educators have not had the

opportunity to learn any of the newer more effective ways of teaching today’s students.

If this is you, you have plenty of resources at hand, such as journals and teachers at your school.

Presenting poor models of behaviour Sometimes we have our days when

things are not going well and we may even take it out on the students without realizing it. It not only damages the relationship you have with them but also gives them the chance to imitate out unfortunate behaviour.

Watch that you model good behaviour even when you do not feel up to it. If you slip, explain to the students why it was wrong and apologize if necessary.

Showing little interest in or appreciation for students

When we disregard them repeatedly, they may be hesitant to approach us again or they seek our attention in disruptive ways.

Be open to your students, greet each of them by name in every class and acknowledge their accomplishments.

Failure to plan proactively Many educators do not plan there

lessons adequately and anticipate problems that might arise, and are not prepared to respond the way they would like.

Think about your lessons in advance and try to anticipate what could happen and be prepared for them.

Using coercion, threat, and punishment If you treat them abrasively they will

keep a watchful eye on you afraid of being scolded, or embarrassed. They may develop negative attitudes towards school and you.

Stop threatening and replace it with good communication and helpfulness.

Explain and demonstrate good behaviour and reward it when you see it.


References

Charles, C. M. (2011). Building Classroom Discipline (tenth edition). Boston: Pearson Education.

Children’s Mental Health Fact Sheet for the Classroom, Oppositional Defiant Disorder. (n.d.). Retrieved February 13th, 2011, from http://www.esu1.org/downloads/psych/ODD.pdf

Fraser, A. 2009. “Oppositional Defiant Disorder.” Australian Family Physician, vol. 37, no.4.

Fox, Lorraine E. Ph.D., CCCW. (1987). Teachers or Taunters: The Dilemma of Providing True Discipline [Electronic version]. Journal of Child and Youth Care Work, 3.

Fox, Lorraine E., Ph.D., (1994). The Catastrophe of Compliance [Electronic version]. The Journal of Child and Youth Care, 9(1).

Halas, J., van Ingen, C. (2009). Gentle Interventions. Reclaiming Children and Youth 18(3), 34-37. Retrieved February 14, 2011, from ERIC database.

Hamilton, S., & Armando, J. 2008. “Oppositional Defiant Disorder.” American Academy of Family Physicians. www.aafp.org/afp. Accessed February 2, 2011.

Lavigne, J.V., Cicchetti, C., Gibbons, R. D., Binns, H. J., Larsen, L., & De Vito, C. (2001). Oppositional defiant disorder with onset in preschool years: Longitudinal stability and pathways to other disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 40 1393-1400.

Petroulakis, E., Morgan, M., LaFleur, P., & Black, S. (2011). Understanding and Responding to the Behavioural Issues of Students Diagnosedwith Oppositional Defiant Disorder, Social Anxiety Disorder and/or Attention Deficit Hyperactivity Disorder in Early and Middle Years.

Trix, Victoria. (2009). Strategies for Teaching Children with oppositional Defiant Disorder. Retrieved February 13th, 2011, from, http://www.brighthub.com/education/special/articles/26631.aspx

Wagner, T. M. (2008) A Guide to Oppositional Defiant Disorder. Retrieved February 13th, 2011, from, http://www.sbbh.pitt.edu/files/pdf/WagnerGuidetoODD.pdf

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