ODD-CD part 12

ODD and CD are usually co-morbid with other problems.  If your child has another co-morbid condition, you should look at the handout for information on the medical and non medical treatment of that disorder

1. if medically treatable CO-morbid conditions are present (ADHD, depression, tic disorders, siezure disorders, psychosis)
2. If non-medical interventions are not successful.
3. When the symptoms are very severe.

In choosing drugs for ODD, look for drugs that have been proven safe in children, have no long term side effects, and have been found in research studies to be effective in extremely aggressive children and adolescents or in CO-morbid conditions which children with CD often have.  Each drug has certain problems that need to be watched for.  The current medical literature suggests three basic principles when using psychiatric drugs in children.  1) Start low,  2) Go slow, and  3) Monitor carefully

This means that you do not start any of these drugs at the usual dose, or the maximum dose.  When you have pneumonia, it can be a real emergency.  You want to give people plenty of medicine right away, and if there is problems, then you reduce it.  Unfortunately, many people use this same strategy in the medical treatment of ODD.  The problem is that big doses can cause big problems, and when the problems affect your mind and personality, this usually means trouble for the person taking the medicines.  So I start with the lowest dose possible.  For example, if I use a drug called Clonidine, for a boy about 60 lb., I know that the dose that will probably work for most boys that size is two pills a day.  If I gave him that to start out with, I might win and it would work.  But if he happens to be sensitive to that drug, he could have big problems.  Although they would be reversible problems, it would probably make most children and adolescents and or parents never want to take the drug again.  So what do I do?  I start with a half of a pill a day, about 25% of the usual dose.  That way if the child is sensitive to the drug, it causes little problems.  I also find that many children respond to drugs at very low doses, far below the usual recommendations.

ODD is not an acute illness.  Less than 10% of the people I see with this need to be treated very quickly.  Most people whom I see with this problem have had it for years.  As a result, there is no need to increase the dose quickly.  By going slowly, it is a lot easier to manage any side effects because things don't happen suddenly.  Also, it is easier to find the lowest effective dose.

For each of the medical treatments for ADHD, there are specific side effects which need to be checked regularly.  Some common ones (see individual drugs below) are monitoring weight so that people are gaining weight, watch for tics, watch for depression, checking blood pressure and pulse, checking blood tests and EKGs, and making sure parents know what the side effects are of the different medications.  In this way, if there is a problem, we can pick it up early and avoid the horror stories, some of which are true, about the medical treatment of this problem.

• Clonidine
• Lithium Carbonate
• Anti-Convulsants=Tegretol (Carbamazepine) and Epival (Depakane in the USA, Valproate)
• Risperidone

Before you can think about doing anything for the child, you and everyone else in the child's environment must feel safe.  You can not say, "no" if you are afraid you might be seriously hurt if you do.  A child will not learn to get along with others if the other children are so afraid of him they will not cross him or her

Every child deserves a safe home, but so does every parent!  If your child is big enough to be dangerous and you can not enforce rules without fear for your safety, then the first thing to do is address this.  Sometimes other interventions can make a big difference right away. Usually they will not.  That means that at least for awhile, the child may have to leave your home.  This might mean foster homes, hospitals, our residential centres.  While this can be a hard thing to do, it is really the only choice at times.  The rest of your family should not have to live in fear.  The child should not learn the intimidation always works, which is often the lesson the child with CD is learning in a home where the parents are afraid.

After a safe home, this is the most important thing.  Other children and teachers need to feel safe in the presence of this child.  This usually means lots and lots of supervision is necessary.  Often it means expulsion and suspensions.  Sometimes this can lead to out of home placement just so the child can be in a safe academic environment

If the child with CD is committing crimes all over your town or village, that will also make any improvement in him impossible.  Some parents, officers, and judges are eager to give a child many "chances".  It is better to jump on these problems early and have an appropriately severe probation, etc., so that everyone is safe.  This teaches the child that actions have consequences and gives people in the community confidence to work with the child.

In many children with CD, the safety issues are never resolved.  Often it is because some person or group keeps wanting to give the child one more try or doesn't think that safety is the most important thing.  All treatments will fail if everyone does not feel safe.  Here are some principals of treatment.

It is easy to get overly involved in one aspect of children such as these.  The fact is, there are usually many parts of their problems.

Family - Many of these children have grown up in abusive homes and/ or may never have had a strong relationship with anyone.  These issues can be addressed through counseling.
Learning - Children with CD frequently have learning disorders.  They need to be assessed and appropriate extra help needs to be given with school work.
Neuropsychiatric - many children with CD also have some other major psychiatric problem.  These need to be vigorously treated.
Social Skills - most children with CD have a very difficult time getting along with others.  This needs to be addressed.  If these problems are addressed, the child with CD has a chance to become one of those who grows out of it.  Without intervening like these, the chances are far less.

Treating the caregivers
This is the most difficult psychiatric disorder of children.  It is still often blamed on the parents or caregivers.  The suggestions for taking care of yourself above need to be followed, but a few more are also necessary.

If you are the full time parent with a child like this, it is a full time job. That means that either both parents/caregivers work part time or one works and the other doesn't. Don't expect to both work full time outside the home.. It won't work. You won't spend every minute with the child, but by the time you address all the needs of the child and yourself and your family, there will be no time for work, too. One of the most impressive changes in children with CD is when they go into a setting in which there is full time parenting (foster care, residential care, or hospital). There is often an almost instant improvement. Why is this? Children with CD need a huge amount of supervision and involvement from the person who is responsible for them. They frequently don't form close relationships easily, they don't do well without structure, and they need to be watched and watched and watched. While Baby sitters, groups, and relatives are great, they are not the same as the parent/principal care giver.

Between living with less, Government agencies, and family, nearly everyone can do this. I find that parents who say that they are going to stay home for their child with CD get a lot of support from families, agencies, and the community. Often money follows.

Whether it is your spouse, relative, friend, pastor, or a counselor, you need to be able to talk to someone with total frankness, especially if things go wrong. You can not do it yourself. Here are some of the common issues which come up.

• Having your child arrested for committing a crime in your home.
• Having people blame you for what the child has done.
• Having large amounts of money disappear and suspecting your child with CD
• Considering out of home placement
• Arranging schooling for a child with CD who has been suspended for the year.
• Having to tell the child he can not stay with you.
• Grieving the loss of the child you hoped you would have.
• Hearing about crimes and wondering if it was your child.
• Seeing the system write your child off.
• Sometimes admitting that you just can not cope with this child.

Here are some recent suggestions which summarize the management of CD and ODD by John Werry, a psychiatrist in Auckland, NZ

• Intervention should be as early as possible.
• It should cover as much of the child's day as possible every day
• It should include all caregivers
• It should be consistent across all environments and across time
• It should be maintained as long as needed (this may be years)
• It should include many different types of interventions and not just focus on one aspect of the problem
• It should address comorbidites such as depression, drug and alcohol abuse, and ADHD

Jean is 8 years old. He has ODD, ADHD and a reading disability. The parents finally got help when Jean's mom was faced with a school suspension after only five days of school. After many battles, things are a little better. To start with, Jean's Dad and mom get a baby sitter three times a week. Sometimes they go out, and sometimes they take the child to the baby-sitter and just go back home. It is these every other day "dates" which see them through this. Jean's parents meet weekly with the school in person, along with a daily report card. Jean gets to use the computer at home only if he does well in school. Jean's Aunt helps twice a week with the reading, as Jean's parents just can not stand to do it. In exchange Jean's mom teaches her nephew piano. Jean takes medication for ADHD which helps, but it is no cure all. He is in Karate, and scouts. About once a week, there is a "problem" in the neighborhood or school which Jean is usually at the center of. Jean wants a dog badly. Through an elaborate Behavior plan, he is slowly "earning" this. Jean feels like everyone is on his case for nothing. It is half true; he is watched closely. Jean's father prays each night that his child will not develop conduct disorder. So far, so good.

Tony is 13 and has conduct disorder and depression. He is living with his Uncle and Aunt who have basically raised him since birth. Occasionally his mom comes by, but not on a regular basis. The father is unknown. Tony's Uncle and Aunt adopted him. They are the head of a "team" which cares for Tony. This includes respite foster parent's two weekends a month, Tony's other uncle one weekend a month, and his grandparents or his adopted parents the other weekend. At the moment, Tony is doing well. After the last sentencing, they were able to get better cooperation from their probation officer and a more workable probation agreement. Tony is supervised more than his adopted parents four year old. Last year he was hospitalized after he cut his wrist after he was caught drinking. Tony is now part of a group at school who are putting together a house. For once he is doing real well, except when he tried to steal an electric saw. But Tony's parents had warned the school to watch for this, and they did, and they caught him. The punishment? No electric guitar for four days. Every week or so while Tony is at school, his parents go through all his stuff. They have told Tony they will do this. Tony thinks it is mean and unfair. On the other hand, there have been no knives in the house for a month now. His parents call it "room service".

In summary, ODD is one bad problem.  There is no one thing that will probably fix it.  Make sure you are not prematurely ruling out any of the possible interventions above.  If you are not careful, it can destroy you long before it ruins the kid.  If nothing is done, the outcome can be dismal.  It is absolutely key to keep working to do everything you can to keep this problem from devastating your life and your child's.

CD is the worst medical or psychiatric problem there is to bear as a parent or caregiver.  If you don't approach this problem with this view, it will most likely devour you.  Even when everything is done right, a bad outcome is still possible.  On the other hand, turning around a child with CD is the most rewarding thing a parent or caregiver can do.  Good luck!