Monday, March 26, 2007

Defiant Johnny

“Johnny is oppositional and defiant! He doesn’t listen… and when you tell him “no” or to do something, he explodes… he screams, hits, kicks… he used to bite… but now he generally just throws things and yells at me. We’ve been at this since he could walk (unspoken: “… and we are very tired”). I can’t even leave him at school (the respite center for most parents)… they call a couple times each week with more complaints… he doesn’t stay in his seat, he doesn’t listen, he hits other kids… plays too rough on the playground. He saw a couple counselors but nothing helps.” This scenario, in various terms by various parents, plays out during the initial screening about 200-300 times each year in our clinic (from among 400 referrals). Interesting (to us), but frustrating to the parents, Johnny sits stoically during the recitation of his “crimes” with nary a complaint nor hint of the symptoms that are tearing this parent (and usually family) apart. Occasionally a parent may go so far as to prod the child into a negative response simply to show that they (the parent) are not lying. Other parents support their argument with a recitation of the teachers, service providers, family, etc. that have been ravaged by their child’s behaviors and concluded the ominous diagnostic verdict, “Your child has oppositional defiant disorder.”

A child who is oppositional and defiant has “oppositional defiant disorder?!?” As professionals, we may need to guard the diagnostic secret that all we do is say “disorder” after the child’s symptoms! Given this line of reasoning, secondary diagnoses for this child could include “scream disorder and kick disorder.” Labeling the child’s symptoms as “oppositional defiant” does not advance understanding of the etiology of symptoms nor potential treatment avenues. Unfortunately, this scenario plays out millions of times each day for children across the country with similar conclusions. The primary cost of this labeling approach to diagnoses is that it tends to result in termination of the search for the underlying etiology or cause for the presenting symptoms. The solution… complete an evaluation or assessment to search for factors that may contribute to the symptoms.

Existing research irrespective of diagnosis indicates that outcomes are related to three factors including: (1) abilities (ie., “hardware” or central nervous system-based processing capacities), (2) skills (ie., acquired responses based on the environment including academic skills, daily living skills, social skills, etc.) and (3) coping resources (ie., “software” packages written by a child in response to the world in which they live). Given this background, a logical extension is that failures of positive outcome (ie., oppositional defiant behaviors) must similarly be related to limitations or deficits related to abilities, skills and coping resources.

What about Johnny? Test results showed strengths across measures of verbal (language), perceptual-motor, learning/memory and higher level reasoning abilities. In contrast, deficits were observed across measures of lower level executive or “conductor” functions including: (a) inhibition (b) rhythm/background tone and (c) “select” (ie., multi-tasking, shifting mental sets, etc.) functions. Deficits in inhibition (or disinhibition) were reflected across external stimuli (ie., short attention span, distractible, etc.), motor responses (ie., hyperactive, hurried, fidgeting, messy, etc.), behavior (ie., rule violations), mood/emotions (ie., irritable, anger, temper tantrums, etc.) and arousal level (ie., difficulties falling asleep, constant motion, broken sleep, etc.). Poor rhythm/background tone was reflected in low frustration tolerance and difficulties adapting to change. Deficient “select” functions were reflected in difficulties with respect to multi-tasking (ie., performing two tasks at once or in rapid/alternating succession) with a high frequency of off-task behaviors (ie., failure to complete assignments, requirements for re-direction and difficulties completing assignments on time). The conclusion…. Johnny’s collection of symptoms/problems (his “ODD”) was related to a breakdown in abilities that warranted a similarly biologically-based (central nervous system) intervention program foundation. Research suggests that an estimated 90% of children with this profile (who also meet ADHD criteria) show benefits to psychostimulant medications.

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