ODD-CD part 10

As far as ODD goes, the same feelings you can have about children and adolescents with ODD have probably influenced the research community.  This is the most common psychiatric diagnosis in children. It persists into adulthood.  One would think a lot of research would be done on this condition. That is not the case.  A search of the medical literature for the last 3 years show 293 articles on ADHD in children, 276 on depression in children, but only 19 on ODD.

The same is not true for CD.  There is a lot of research on different treatment methods for this problem.  There are hundreds of psychological techniques which have been tried, but none have been found to be always successful.  They involve behavior modification, working with families, and tight supervision.  The best results have been found with what is called multisystem therapy.  What that means is, do a lot of different things at the same time.  As far as this pamphlet goes, it means you should not rely on just one type of intervention.  Ideally, you should use a little of all of them.  Overall, since CD is usually just a very severe form of ODD, all of the below can be useful in CD.  At the end of this section are some other suggestions for CD.

Treating the comorbid disorders is absolutely key.  Recent studies have shown that treating CD plus ADHD with stimulants helps the conduct disorder and the ADHD symptoms.  This effect appears independent of how bad the ADHD is.  Since 60-70% of children who go to a clinic for help with CD also have ADHD, this is extremely important.  Serious consideration should be given to medically treating all children with CD plus ADHD.  Although this type of medical intervention does not make the children "normal", it can make a big difference.  It often means that the non-medical interventions will work much better.

Recent work also suggests that treating depression in the context of CD be effective.  While Prozac was used in this study, most likely other drugs in that same family would be effective.

Although there is not as much data on these areas, it is a good idea to always vigorously treat any disorder comorbid with CD.  The importance of treating comorbid conditions can not be overstated.

The essence of this group of interventions is to make it impossible for ODD to "work."  That is, it is a way of making sure all these attempts to irritate and annoy others and to cause fighting between others are not successful.
There are three elements to this.

1. Come together
The most common thing I see in children with ODD (except for aggressiveness) is that a lot of the suffering that the child inflicts on others is blamed on others.  Children and adolescents with ODD convince mothers that fathers have mistreated them.  They convince parents that the teachers are treating their child unfairly.  They convince teachers that the parents are bad, etc.  You have to come together and never believe anything the child with ODD tells you about how others treat them.  In order to do this, all parties need to talk directly with each other without the child as an intermediary.  Mothers need to talk face to face with fathers.  Parents need to talk with teachers and with principals.  Sometimes Parole officers, parents, teachers and others have to all sit down together for the purpose of making it impossible for the child to play one person or group off against another.  Here are some concrete suggestions.  Ask to sit down with the principals and teachers regularly.  Make it school and home policy to never rely on information your child with ODD gives you about what others have done.  Do not include the child in these discussions.  Sit down with all caregivers (grandparents, uncles, baby-sitters, parents, etc.) to make sure they understand ODD and they follow the above policy.

2. Have a plan
That is, a plan to deal with all of this oppositional and defiant behavior.   If you react on the spur of the moment, your emotions will guide you wrongly in dealing with children and adolescents with ODD.  They will work to provoke intense feelings in everyone.  Everyone needs to agree on what happens when the child with ODD does certain things.  What do we do if she disrupts class, annoys others incessantly, fights, has a major temper tantrum, states she is going to kill herself or run away?  You need a behavior modification or management plan.
Is that what "1-2-3 Magic" is?
Yes, that is a good example.  For behavior modification to work, the program must have certain properties:

1. A few important behaviors need to be targeted. Rather than targeting "being good," you might try no hitting and no swearing.
2. The behavior must be clear cut and not fuzzy. Things like "listen when I tell you something" won't work, because it is too unclear. A better idea would be, "Sit down and look at me when I ask you to listen."
3. It must be consistent. There is no bending of rules in this sort of thing: no difference between the baby-sitter, mom, or dad.
4. The rewards and punishments need to be geared to the individual.
5. The rewards should not be money or things that are bought, but rather should be privileges which you can grant or activities which the child can do. Behavior Modification should not require a bank loan.
6. There needs to be an even mix of negative and positive reinforcers. The program should not be like candyland, but it also should not be out of Dorchester Prison. A typical Positive one would be a later bedtime on the weekend or a choice of dinner. A typical negative one would be going to your room or no TV.
7. It should be simple and straightforward so that your child easily understands it. If your child can read, it should be written down. If possible, your child should sign it and agree to it.
   

Almost every book on ADHD contains many good examples of these programs. I have some, all the family resource centers do, and so do libraries and book stores.

Jim never comes home when he is supposed to. This drives his parents nuts and they would like to kill him when he finally does come home. The behavior they want is to have Jim come home on time.

The good parents The positive reinforcer (the carrot) would be if he comes home on time for 5 days, he can have a friend stay over and they can stay up late. The negative reinforcer (the stick) would be that if you are more than 5 minutes late, you will not be able to go out by yourself the next day. You will have to go out with the parent when it is convenient for the parent.

The Candyland parents If you come home on time, we will pay you five dollars or you will be able to stay up as late as you want at our house that night. If you don't come home, nothing bad will happen.

The Dorchester Prison Parents If you are one minute late, you will be grounded for a week to your room.