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Challenges in Treating Oppositional Defiant Disorder in a Pediatric Medical Setting: A Case Study
Journal of Pediatric Nursing (2012) 27, 557–562
Challenges in Treating Oppositional Defiant Disorder in a Pediatric Medical Setting: A Case Study Ann M. Kledzik MD a , Michele C. Thorne PhD, HSPP a,⁎, Vivek Prasad MD b , Kathy H. Hayes LCSW c , Lori Hines RN c a
Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN Indiana University, General Psychiatry Residency 2010, Indianapolis, IN c Psychiatry Consultation/Liaison Service, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN b
Key words: Critically ill children; Oppositionality and defiance; Nursing training; Behavior modification
The following case study is presented to highlight the importance of consistency in identifying and treating oppositional defiant disorder in a pediatric patient with a life-threatening medical illness. A pediatric transplant patient's oppositional behaviors are described, as well as the educational behavioral training program provided to the patient's caregivers and medical staff. As a result of the training, the patient engaged in less oppositional behavior, was more cooperative and pleasant with staff, and was more compliant with her treatment. Subjective reports from caregivers indicated that the training with its emphasis on consistency effectively reduced the patient's symptoms and enhanced the caregivers' ability to care for the patient. © 2012 Elsevier Inc. All rights reserved.
THE MANAGEMENT OF oppositional defiant disorder (ODD) in the medical inpatient setting is not well defined in the literature. Children who display oppositional symptoms prior to becoming physically ill often experience an exacerbation of their behavior problems when undergoing the stress of a prolonged medical hospitalization. In these cases, multiple complexities arise that may interfere with medical treatment and may prompt psychiatric consultation. Addressing behaviors that interfere with medical treatment is critically important in a pediatric medical setting, as compliance with medical treatments can mean the difference between life and death. In this case report, we first provide a brief review of ODD and its outpatient management. We then describe the treatment of ODD in a hospitalized, severely medically ill child and the intervention designed to target challenging behavior in a pediatric medical setting.
⁎ Corresponding author: Michele C. Thorne, PhD, HSPP. E-mail address: [email protected] (M.C. Thorne). 0882-5963/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.06.006
Symptoms of ODD In outpatient psychiatry clinics, ODD is one of the most prevalent disorders in children and adolescents (McMahon & Forehand, 2003). The constellation of symptoms was first conceptualized as a diagnosis in 1966. ODD first appeared as a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III; American Psychiatric Association, 1980). It is included in the category of disruptive behavior disorders, along with attention-deficit/ hyperactivity disorder (ADHD) and conduct disorder. According to the DSM-IV, ODD is diagnosed when a child displays a persistent pattern of disobedience and hostility toward parents, teachers, and authority figures (American Psychiatric Association, 2000). Opposition to authority and active defiance comprise the two main problems areas displayed in ODD. The child consistently refuses to follow commands and requests made by adults. The child is easily annoyed by others, repeatedly loses his temper, argues with adults, refuses to comply with adults' requests or rules,
558 deliberately annoys people, often blames others for his or her mistakes or misbehavior, and is often spiteful or vindictive. This child is often hostile and verbally aggressive. Physical aggression may also occur but is usually less common. Children who are defiant often are described as stubborn and resistive to authority. In addition, these children often have difficulties with peer interactions and are unwilling to give in, compromise, or negotiate with their peers. Without treatment, these problems worsen, and children with ODD become increasingly hostile, are less able to withstand provoking from peers, and are more disrespectful to adults (Frankel & Feinberg, 2002). In addition, these behaviors must occur more often than expected for children of the same age and developmental level. The behaviors are significant enough as to impair the child's ability to perform in academic settings and at home. This constellation of symptoms is often referred to as noncompliance. In outpatient settings, noncompliance is often seen as ignoring parental requests and refusing to follow through with an adult's request. Noncompliance also includes a child's refusal to engage in previously learned rules of conduct (i.e., running away from a parent in a store). In medical settings, an additional component of noncompliance is present. It is often referred to as nonadherence, meaning that the child is not adhering to the specified medical plan (LaGreca & Bearman, 2003). Nonadherence includes such behaviors as forgetting to take medication and refusal to engage in all or parts of the medical treatment plan. In a child who also exhibits oppositional and defiant behaviors, nonadherence can include lying about following the treatment plan, refusal to engage in certain aspects of treatment (i.e., patients with cystic fibrosis refusing to complete daily vest treatments), engaging in behaviors that negatively impact the patient's health, and hiding or flushing medications. Adherence in pediatric populations is influenced by “degree of psychological distress, family functioning, and physiological side-effects of medications” (Griffin & Elkin, 2001, p. 246). An increased level of psychological distress (both in the patient and family members) is linked to higher rates of nonadherence, as are social factors such as living in a single-parent home, witnessing familial discord, and economic strife (Berquist et al., 2006; Griffin & Elkin, 2001; Lurie et al., 2000).
A.M. Kledzik et al. 2000). Children with oppositional and defiant behaviors have been found to have more difficult temperaments, poor frustration tolerance, and poor habit regulation. Caregivers and family members of these children tend to use harsh and inconsistent discipline techniques. ODD tends to be more common in families where caregivers have a history of mood problems, oppositional and defiant behaviors, poor attention and impulsivity, and substance problems (American Psychiatric Association, 2000). In addition, social characteristics such as being raised in a single-parent household have been linked to the development of oppositional and defiant behaviors in children (Frankel & Feinberg, 2002; McMahon & Forehand, 2003).
Rationale for Treating ODD The class of disruptive behavior disorders is the leading referral problem in outpatient psychiatric clinics (Nock et al., 2007). In addition, the behaviors associated with ODD are pervasive and typically worsen if no action is taken (Barkley, 1997). In addition, the child's oppositional and defiant behaviors are often present in multiple settings and affect the child's relationships with multiple individuals. Children with ODD often have difficult peer interactions, difficulties with teachers, and problems getting along with others in social settings (Frankel & Feinberg, 2002). These social impairments affect the family as well; many parents with children who exhibit oppositional and defiant behaviors report that they avoid asking their child to complete tasks rather than risk noncompliance, or ask siblings to do extra work, often causing sibling relational problems. Finally, many parents report more negative interactions with children diagnosed with ODD and few positive interactions. An additional concern is related to the stability of noncompliance and defiant behaviors. These behaviors are highly stable over time and are correlated with later conduct problems and poor academic problems (Frankel & Feinberg, 2002; Barkley, 1997). As a result, the presence of these behaviors warrants intervention. The next section will discuss the available treatment options for ODD.
Correlates of ODD
Behavioral Interventions for ODD
The lifetime prevalence of ODD is estimated to be 10.2% and is highly comorbid with mood, anxiety, impulse-control, and substance use disorders (Nock, Kazdin, Hiripi, & Kessler, 2007). Although no single cause has been identified, many risk factors and co-occurring features have been identified. The relationship between parent and child is often highlighted as being problematic in children who are later diagnosed with ODD. The relationship is characterized as involving multiple and repeated conflicts and inconsistency in parental interactions (American Psychiatric Association,
Behavioral interventions are the first line of treatments sought for ODD. There are multiple components to behavioral interventions, but most focus on improving the interactions between caregivers and children. This is often done by engaging caregivers in parent training and teaching them ways to change interactions with their children. This section will briefly highlight several of the key components to successful behavioral interventions. The first task is to establish a therapeutic alliance with the child and family while empathizing with the child's frustration and anger.
Challenges in Treating Oppositional Defiant Disorder in a Pediatric Population Two of the most important pieces of effective interventions include the use of praise and positive reinforcement for appropriate behaviors (Dumas, 2002; Barkley, 1997). Parents and children have often entered a cycle of negative interactions, and teaching parents to focus on what their children do well is often the first step to stopping this cycle. Praise and reinforcement serve multiple purposes, including building children's self-esteem and strengthening the bond between caregivers and children. To be effective, praise must occur often, be specific to the child's behavior, and be genuine (Barkley, 1997; Dumas, 2002). Likewise, reinforcement should be small and frequent, occur immediately after the desired behavior, and be combined with praise. Various reinforcement strategies exist, and families and therapists should work together to develop a menu of rewards that are meaningful to the child. These are then combined with a behavior plan, which focuses on two to three target behaviors that the caregivers have identified as most problematic. Behaviors should be easy to evaluate, and the instructions should be phrased positively so that they tell the child what to do rather than what not to do (i.e., “Keep your hands and feet to yourself” rather than “Don't hit”). The instructions should also specify the length of time the behavior is expected (i.e., during school periods, at home, hourly, etc.). Additional key components of effective behavior plans include setting limits for behavior, learning to give effective instructions, and using active ignoring. Caregivers are instructed in how to use these techniques and how to evaluate the behaviors. A crucial aspect of these plans involves the importance of consistency with respect to response to behaviors and application of consequences (American Academy of Child and Adolescent Psychiatry, 2007). By using consistent consequences, parents avoid unintentionally reinforcing the child's behavior by giving into demands and cajoling. Such consequences may include the use of time out and removal of privileges (Barkley, 1997; Dumas, 2002). At times, a child's behavior may become so aggressive or destructive that adjunctive pharmacologic intervention is necessary. The following section will highlight pharmacologic options.
Pharmacologic Treatment of ODD The American Academy of Child and Adolescent Psychiatry has published practice parameters for the evaluation and treatment of ODD. Most studies that have examined pharmacologic treatment of ODD have focused on patients with comorbidities such as ADHD and mood disorder. Several medications such as stimulants and atomoxetine, used to treat impulsive behaviors in ADHD, may result in improvement of ODD symptoms (American Academy of Child and Adolescent Psychiatry, 2007). These improvements, however, are likely more directly related to the treatment of underlying symptoms of irritability, impulsivity, or anxiety (Turgay, 2009). There is little data regarding the use of medication for children with ODD who
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do not have other psychiatric comorbidities. Medication use for ODD is often reserved for patients who have not benefited from behavioral interventions or who have significant symptoms of aggression or other behaviors that impair their functioning. When pharmacologic treatment is prescribed to target these behaviors, it should be used in conjunction with ongoing behavior therapy. Although these guidelines are clearly laid out for practitioners in the outpatient setting, similar guidelines are less well defined for treating ODD in an inpatient pediatric medical setting. In our tertiary-care hospital, we encounter this situation regularly and are charged with addressing these behaviors in seriously medically ill children. The following case highlights key issues and challenges that can arise in treating children with ODD.
Patient Presentation Patient A is a prepubescent female hospitalized with multiorgan system failure related to nonadherence with prior treatment recommendations. She required significant medical intervention including organ transplantation due to the severity of her illness. Posttransplant, she required a protracted hospitalization due to a slow recovery and infections requiring IV antibiotics. Prior to this hospitalization, she displayed oppositional behavior such as arguing and refusing to follow directions, refusing to accept responsibility for her actions, refusing to take her medications, and hiding medications from her mother. For transplant patients, one of the most critical keys to survival is adherence to their medication regimen. Rejection of organs can often occur when patients do not adhere to this regimen (Rodrigue & Zelikovsky, 2009). The consultation-liaison (C/L) psychiatry service was asked to see the patient during her hospitalization to evaluate for depression and to help manage oppositional behaviors. Initially after transplant, she refused to talk or to get out of bed, prompting concern for depression. Her defiance quickly began to hinder the nursing staff's attempts to care for the patient. She exhibited significant oppositional behaviors including yelling, refusing to respond to caregivers' questions, and pleading with nursing staff to avoid activities such as getting out of bed, walking around the unit, and engaging in physical therapy. She became aggressive toward nurses on several occasions when they were attempting to do dressing changes or administer medications. She was also noted to say hurtful things to the nursing staff and to accuse nursing staff of maltreatment. Because of the necessary intensity of her care and the significant problem behaviors, nursing staff were requiring increasing amounts of time to perform their duties for this patient and subsequently had less time for other patients. These interactions also led to a significant decrease in nursing morale. Nurses also reported that they feared being reprimanded for “maltreatment” of the patient.
560 A behavior plan was created by the C/L team in conjunction with the nursing staff with three target goals of (a) taking medications, (b) walking around the unit three times a day, and (c) allowing dressing changes. When compliant with one of these goals, the patient earned stickers that could be exchanged for a “reward” such as computer time, watching a movie, or special time with a staff member doing activities such as manicures. When noncompliant with these target goals or when verbally or physically aggressive, opportunities to earn rewards were withheld, and attention was withdrawn for a brief period unless medically necessary. Several challenges arose during the implementation of this behavior plan, the most significant of which was difficulty establishing consistency. The patient had as many as 30 different nurses and patient care technicians during the week and each caregiver had his or her own style of “parenting.” Some felt that the patient should not be made to walk everyday when she complained of pain, whereas others suspected that her physical complaints were excuses not to comply with her schedule. Some voiced fear of being removed from their duties due to complaints of maltreatment by the patient when staff attempted to adhere to the behavior plan. Several stated that it was easier to allow the patient to be noncompliant with the behavior plan rather than attempt to enforce it. Reinforcing the patient in this way by allowing noncompliance created a type of intermittent reinforcement. Because this patient was reinforced for being noncompliant at times, there was no incentive for her to follow the behavior plan, thus making her behaviors even more difficult to extinguish. In addition to discrepancies between nursing staff enforcement, the patient's mother also presented challenges to following the behavior plan. When the patient's mother was present, she would not withdraw privileges for noncompliance and would instruct nurses that the patient should be allowed to refuse to complete her daily tasks if not feeling well. Nurses were then faced with the dilemma of whether to follow the mother's instructions or adhere to the behavior plan. When the patient was physically aggressive toward nursing staff, her mother questioned what had been done to her to provoke this response and did not give the patient consequences for her behavior. Implementation of this behavior plan also encountered resistance from the medical service who was not familiar with the diagnosis or implications of ODD. On several occasions, the medical team allowed the patient to be excused from completing her daily tasks if she offered resistance to the nursing staff. This reinforced the patient's actions and prompted greater refusal the next time she was required to do a task. Multiple meetings were convened with nursing staff, ancillary medical staff (including patient care technicians, child life specialists, social work, and chaplaincy), and the C/L psychiatry service to determine how best to help this patient. It became clear that the medical staff caring for the patient would benefit from additional education on symptoms and management of ODD as parents are educated
A.M. Kledzik et al. in the outpatient setting. Two separate 3-hour training sessions were organized to educate nurses, child life personnel, and occupational and physical therapists in how to manage oppositional behaviors. This training was based on Dr. Russell Barkley's extensive work with oppositional and defiant children (Barkley, 1997). The first portion of the training session consisted of an informative discussion on symptoms of ODD and management techniques, including reward systems to increase desired behaviors and appropriate consequences for noncompliance. The second portion of the training involved a role-play with a mock patient who simulated typical behaviors of this patient on the medical unit, as well as the most common problematic interactions with nursing staff (i.e., when the patient engaged in complaining or stalling behaviors, the nurses practiced active ignoring and matter-of-fact interactions). The patient's mother was also given the opportunity to participate in behavioral management training to ensure that the behavior plan would continue to be implemented at home after discharge. The patient's mother was able to practice using these skills in the inpatient setting while receiving feedback and guidance from the C/L psychiatry team. In follow-up meetings with staff, direct care nurses reported feeling empowered to care for this patient and as having necessary tools to perform their duties. By using techniques learned in the training session, nurses were able to decrease time spent persuading the patient to comply and subsequently reported more positive interactions, both with the patient and her mother. The nursing staff reported that the patient's mood substantially improved, and she was more polite with requests and engaged in less disrespectful behavior. As the patient's hospitalization was further prolonged by medical complications, medical staff became less consistent with the behavior plan, and the patient's previous disruptive and oppositional behaviors resurfaced at a level of severity equivalent to that seen prior to training. As a result, the C/L psychiatry team met with nursing supervisors to create additional training opportunities for staff, including reviewing didactic material, identifying nurses to model appropriate interventions for other staff, and encouraging the patient's mother to enforce the plan when the patient was in her care. Following further training, the patient's problematic behavior again decreased until the time of her discharge. Outpatient follow-up was arranged to ensure that the patient's mother continued to have support and guidance regarding behavior modification strategies after her child's discharge.
Discussion As illustrated in the case above, there are several key issues when treating ODD in the pediatric medical setting. Because of the large number of caregivers involved in the treatment of such a patient, ensuring consistency with a behavior plan can be challenging. In the outpatient setting, therapists typically have to gain buy-in from only two
Challenges in Treating Oppositional Defiant Disorder in a Pediatric Population caregivers, the child's parents or guardians. In the hospital setting, as illustrated above, different “parenting” styles of up to 30 caregivers can complicate the therapeutic approach. Providing comprehensive training for all those participating in the direct care of the patient can be an effective way of enhancing consistency with behavior modification strategies. Another complicating factor is the child's medical illness. Often, caregivers are reluctant to enforce discipline strategies because the child is ill, thereby unwittingly reinforcing and eventually worsening behaviors. In our experience, balancing empathy for a child's physical symptoms with behavior modification of oppositional symptoms can be a difficult task. Parents often become more lenient with negative behaviors when a child is ill, which can lead to more significant problems once the illness resolves (Wells, 2003). Open communication between the medical team, nursing staff, and parents can help to determine when a child is too ill to comply with behavioral expectations. Typically, even when extremely ill, a child should still be expected to maintain a level of respect for those around her, and it should be emphasized that physical aggression is never acceptable. It is important to have the parents participate in the day-today management of ODD while the child is hospitalized to ensure continued adherence after discharge.
Ethical Considerations As illustrated in the case above, the presence of oppositional and defiant behaviors can have life-threatening consequences when the child also has a serious medical condition. Pediatric transplant patients have been found to have up to a 40% nonadherence rate with their treatment regimens due to problems with forgetfulness, side effects, and financial pressures related to paying for medications (Berquist et al., 2006). When these problems coexist with oppositional and defiant behaviors, the nonadherence rate can further increase. As a result, it is essential that during pretransplant evaluations, evaluators conduct a thorough psychosocial assessment to elucidate any potential problems or areas of concern. Both parents and medical staff should receive training to address factors that increase nonadherence, including behaviors such as oppositionality and defiance. All members of the treatment team should receive this training, and the treatment regimen should include regular evaluation of progress and trouble-shooting of problems that arise. A list of references for providers is provided below.
Future Directions Further directions for study include objective measures of the effectiveness of training sessions, both in terms of decreasing oppositional and defiant behaviors and improving
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caregivers' adherence to the behavior plan, consistency among caregivers, and morale of nursing staff. Pharmacologic treatment of aggressive and defiant behaviors should also be an area of investigation, especially in terms of drug interactions with other medications and when to initiate medications in addition to behavioral techniques.
Additional Resources for Nurses and Parents Websites:American Academy of Child and Adolescent Psychiatry: http: //www.aacap.org/cs/ODD.ResourceCenter#AboutODD. American Academy of Pediatrics http://www.healthychildren.org/English/health-issues/conditions/adhd/pages/Behavior-Therapy-ParentTraining.aspx. Mayo Clinic: http://www.mayoclinic.com/health/oppositional-defiantdisorder/DS00630. Books:Barkley, R. A., & Benton, C. M. (1998). Your defiant child: Eight steps to better behavior. New York, NY: The Guilford Press. Kazdin, A. E. (2009). The Kazdin method for parenting the defiant child. New York, NY: Houghton Mifflin. Phelan, T. (2010). 1,2,3 Magic: Effective discipline for children 2–12 (advice on parenting). Glen Ellyn, IL: ParentMagic, Inc.
Acknowledgments There are no financial disclosures to make.
References American Academy of Child and Adolescent Psychiatry. (2007). Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 126–141. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3th ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: American Psychiatric Association. Barkley, R. A. (1997). Defiant children: A clinician's manual for assessment and parent training (2nd ed.). New York, NY: The Guilford Press. Berquist, R. K., Berquist, W. E., Esquivel, C. O., Cox, K. L., Wayman, K. I., & Litt, I. F. (2006). Adolescent non-adherence: Prevalence and consequences in liver transplant recipients. Pediatric Transplantation, 10, 304–310. Dumas, J. E. (2002). PACE-Parenting our children to excellence: A program to promote parenting effectiveness and child coping-competence in the preschool years. Frankel, F., & Feinberg, D. (2002). Social problems associated with ADHD vs. ODD in children referred for friendship problems. Child Psychiatry and Human Development, 33, 125–146. Griffin, K. J., & Elkin, T. D. (2001). Non-adherence in pediatric transplantation: A review of the existing literature. Pediatric Transplantation, 5, 246–249. LaGreca, A. M., & Bearman, K. J. (2003). Adherence to pediatric treatment regimens. In M. C. Roberts (Ed.), Handbook of pediatric psychology (3rd ed.) pp. 119–140. Lurie, S., Shemesh, E., Sheiner, P. A., Emre, S., Tindle, H. L., Melchionna, L., et al. (2000). Non-adherence in pediatric liver transplant
562 recipients—An assessment of risk factors and natural history. Pediatric Transplantation, 4, 200–206. McMahon, R. J., & Forehand, R. L. (2003). Helping the noncompliant child: Family based treatment for oppositional behavior (2nd ed.). New York, NY: The Guilford Press. Nock, M. K., Kazdin, A. E., Hiripi, E., & Kessler, R. C. (2007). Lifetime prevalence, correlates and persistence of oppositional defiant disorder: Results from the National Comorbidity Survey Replication. Journal of Child Psychology and Psychiatry, 48, 703–713.
A.M. Kledzik et al. Rodrigue, J. R., & Zelikovsky, N. (2009). Pediatric organ transplantation. In M. C. Roberts, & R. G. Steele (Eds.), Handbook of pediatric psychology (4th ed., pp. 392–402). Turgay, A. (2009). Psychopharmacological treatment of oppositional defiant disorder. CNS Drugs, 23, 1–17. Wells, K. C. (2003). Adaptations for specific populations. In R. J. McMahon, & R. L. Forehand (Eds.), Helping the noncompliant child: Family based treatment for oppositional behavior (2nd ed., pp. 182–200). New York, NY: The Guilford Press.
Challenges in Treating Oppositional Defiant Disorder in a Pediatric Medical Setting: A Case Study Ann M. Kledzik MD a , Michele C. Thorne PhD, HSPP a,⁎, Vivek Prasad MD b , Kathy H. Hayes LCSW c , Lori Hines RN c a
Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN Indiana University, General Psychiatry Residency 2010, Indianapolis, IN c Psychiatry Consultation/Liaison Service, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN b
Key words: Critically ill children; Oppositionality and defiance; Nursing training; Behavior modification
The following case study is presented to highlight the importance of consistency in identifying and treating oppositional defiant disorder in a pediatric patient with a life-threatening medical illness. A pediatric transplant patient's oppositional behaviors are described, as well as the educational behavioral training program provided to the patient's caregivers and medical staff. As a result of the training, the patient engaged in less oppositional behavior, was more cooperative and pleasant with staff, and was more compliant with her treatment. Subjective reports from caregivers indicated that the training with its emphasis on consistency effectively reduced the patient's symptoms and enhanced the caregivers' ability to care for the patient. © 2012 Elsevier Inc. All rights reserved.
THE MANAGEMENT OF oppositional defiant disorder (ODD) in the medical inpatient setting is not well defined in the literature. Children who display oppositional symptoms prior to becoming physically ill often experience an exacerbation of their behavior problems when undergoing the stress of a prolonged medical hospitalization. In these cases, multiple complexities arise that may interfere with medical treatment and may prompt psychiatric consultation. Addressing behaviors that interfere with medical treatment is critically important in a pediatric medical setting, as compliance with medical treatments can mean the difference between life and death. In this case report, we first provide a brief review of ODD and its outpatient management. We then describe the treatment of ODD in a hospitalized, severely medically ill child and the intervention designed to target challenging behavior in a pediatric medical setting.
⁎ Corresponding author: Michele C. Thorne, PhD, HSPP. E-mail address: [email protected] (M.C. Thorne). 0882-5963/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.06.006
Symptoms of ODD In outpatient psychiatry clinics, ODD is one of the most prevalent disorders in children and adolescents (McMahon & Forehand, 2003). The constellation of symptoms was first conceptualized as a diagnosis in 1966. ODD first appeared as a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III; American Psychiatric Association, 1980). It is included in the category of disruptive behavior disorders, along with attention-deficit/ hyperactivity disorder (ADHD) and conduct disorder. According to the DSM-IV, ODD is diagnosed when a child displays a persistent pattern of disobedience and hostility toward parents, teachers, and authority figures (American Psychiatric Association, 2000). Opposition to authority and active defiance comprise the two main problems areas displayed in ODD. The child consistently refuses to follow commands and requests made by adults. The child is easily annoyed by others, repeatedly loses his temper, argues with adults, refuses to comply with adults' requests or rules,
558 deliberately annoys people, often blames others for his or her mistakes or misbehavior, and is often spiteful or vindictive. This child is often hostile and verbally aggressive. Physical aggression may also occur but is usually less common. Children who are defiant often are described as stubborn and resistive to authority. In addition, these children often have difficulties with peer interactions and are unwilling to give in, compromise, or negotiate with their peers. Without treatment, these problems worsen, and children with ODD become increasingly hostile, are less able to withstand provoking from peers, and are more disrespectful to adults (Frankel & Feinberg, 2002). In addition, these behaviors must occur more often than expected for children of the same age and developmental level. The behaviors are significant enough as to impair the child's ability to perform in academic settings and at home. This constellation of symptoms is often referred to as noncompliance. In outpatient settings, noncompliance is often seen as ignoring parental requests and refusing to follow through with an adult's request. Noncompliance also includes a child's refusal to engage in previously learned rules of conduct (i.e., running away from a parent in a store). In medical settings, an additional component of noncompliance is present. It is often referred to as nonadherence, meaning that the child is not adhering to the specified medical plan (LaGreca & Bearman, 2003). Nonadherence includes such behaviors as forgetting to take medication and refusal to engage in all or parts of the medical treatment plan. In a child who also exhibits oppositional and defiant behaviors, nonadherence can include lying about following the treatment plan, refusal to engage in certain aspects of treatment (i.e., patients with cystic fibrosis refusing to complete daily vest treatments), engaging in behaviors that negatively impact the patient's health, and hiding or flushing medications. Adherence in pediatric populations is influenced by “degree of psychological distress, family functioning, and physiological side-effects of medications” (Griffin & Elkin, 2001, p. 246). An increased level of psychological distress (both in the patient and family members) is linked to higher rates of nonadherence, as are social factors such as living in a single-parent home, witnessing familial discord, and economic strife (Berquist et al., 2006; Griffin & Elkin, 2001; Lurie et al., 2000).
A.M. Kledzik et al. 2000). Children with oppositional and defiant behaviors have been found to have more difficult temperaments, poor frustration tolerance, and poor habit regulation. Caregivers and family members of these children tend to use harsh and inconsistent discipline techniques. ODD tends to be more common in families where caregivers have a history of mood problems, oppositional and defiant behaviors, poor attention and impulsivity, and substance problems (American Psychiatric Association, 2000). In addition, social characteristics such as being raised in a single-parent household have been linked to the development of oppositional and defiant behaviors in children (Frankel & Feinberg, 2002; McMahon & Forehand, 2003).
Rationale for Treating ODD The class of disruptive behavior disorders is the leading referral problem in outpatient psychiatric clinics (Nock et al., 2007). In addition, the behaviors associated with ODD are pervasive and typically worsen if no action is taken (Barkley, 1997). In addition, the child's oppositional and defiant behaviors are often present in multiple settings and affect the child's relationships with multiple individuals. Children with ODD often have difficult peer interactions, difficulties with teachers, and problems getting along with others in social settings (Frankel & Feinberg, 2002). These social impairments affect the family as well; many parents with children who exhibit oppositional and defiant behaviors report that they avoid asking their child to complete tasks rather than risk noncompliance, or ask siblings to do extra work, often causing sibling relational problems. Finally, many parents report more negative interactions with children diagnosed with ODD and few positive interactions. An additional concern is related to the stability of noncompliance and defiant behaviors. These behaviors are highly stable over time and are correlated with later conduct problems and poor academic problems (Frankel & Feinberg, 2002; Barkley, 1997). As a result, the presence of these behaviors warrants intervention. The next section will discuss the available treatment options for ODD.
Correlates of ODD
Behavioral Interventions for ODD
The lifetime prevalence of ODD is estimated to be 10.2% and is highly comorbid with mood, anxiety, impulse-control, and substance use disorders (Nock, Kazdin, Hiripi, & Kessler, 2007). Although no single cause has been identified, many risk factors and co-occurring features have been identified. The relationship between parent and child is often highlighted as being problematic in children who are later diagnosed with ODD. The relationship is characterized as involving multiple and repeated conflicts and inconsistency in parental interactions (American Psychiatric Association,
Behavioral interventions are the first line of treatments sought for ODD. There are multiple components to behavioral interventions, but most focus on improving the interactions between caregivers and children. This is often done by engaging caregivers in parent training and teaching them ways to change interactions with their children. This section will briefly highlight several of the key components to successful behavioral interventions. The first task is to establish a therapeutic alliance with the child and family while empathizing with the child's frustration and anger.
Challenges in Treating Oppositional Defiant Disorder in a Pediatric Population Two of the most important pieces of effective interventions include the use of praise and positive reinforcement for appropriate behaviors (Dumas, 2002; Barkley, 1997). Parents and children have often entered a cycle of negative interactions, and teaching parents to focus on what their children do well is often the first step to stopping this cycle. Praise and reinforcement serve multiple purposes, including building children's self-esteem and strengthening the bond between caregivers and children. To be effective, praise must occur often, be specific to the child's behavior, and be genuine (Barkley, 1997; Dumas, 2002). Likewise, reinforcement should be small and frequent, occur immediately after the desired behavior, and be combined with praise. Various reinforcement strategies exist, and families and therapists should work together to develop a menu of rewards that are meaningful to the child. These are then combined with a behavior plan, which focuses on two to three target behaviors that the caregivers have identified as most problematic. Behaviors should be easy to evaluate, and the instructions should be phrased positively so that they tell the child what to do rather than what not to do (i.e., “Keep your hands and feet to yourself” rather than “Don't hit”). The instructions should also specify the length of time the behavior is expected (i.e., during school periods, at home, hourly, etc.). Additional key components of effective behavior plans include setting limits for behavior, learning to give effective instructions, and using active ignoring. Caregivers are instructed in how to use these techniques and how to evaluate the behaviors. A crucial aspect of these plans involves the importance of consistency with respect to response to behaviors and application of consequences (American Academy of Child and Adolescent Psychiatry, 2007). By using consistent consequences, parents avoid unintentionally reinforcing the child's behavior by giving into demands and cajoling. Such consequences may include the use of time out and removal of privileges (Barkley, 1997; Dumas, 2002). At times, a child's behavior may become so aggressive or destructive that adjunctive pharmacologic intervention is necessary. The following section will highlight pharmacologic options.
Pharmacologic Treatment of ODD The American Academy of Child and Adolescent Psychiatry has published practice parameters for the evaluation and treatment of ODD. Most studies that have examined pharmacologic treatment of ODD have focused on patients with comorbidities such as ADHD and mood disorder. Several medications such as stimulants and atomoxetine, used to treat impulsive behaviors in ADHD, may result in improvement of ODD symptoms (American Academy of Child and Adolescent Psychiatry, 2007). These improvements, however, are likely more directly related to the treatment of underlying symptoms of irritability, impulsivity, or anxiety (Turgay, 2009). There is little data regarding the use of medication for children with ODD who
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do not have other psychiatric comorbidities. Medication use for ODD is often reserved for patients who have not benefited from behavioral interventions or who have significant symptoms of aggression or other behaviors that impair their functioning. When pharmacologic treatment is prescribed to target these behaviors, it should be used in conjunction with ongoing behavior therapy. Although these guidelines are clearly laid out for practitioners in the outpatient setting, similar guidelines are less well defined for treating ODD in an inpatient pediatric medical setting. In our tertiary-care hospital, we encounter this situation regularly and are charged with addressing these behaviors in seriously medically ill children. The following case highlights key issues and challenges that can arise in treating children with ODD.
Patient Presentation Patient A is a prepubescent female hospitalized with multiorgan system failure related to nonadherence with prior treatment recommendations. She required significant medical intervention including organ transplantation due to the severity of her illness. Posttransplant, she required a protracted hospitalization due to a slow recovery and infections requiring IV antibiotics. Prior to this hospitalization, she displayed oppositional behavior such as arguing and refusing to follow directions, refusing to accept responsibility for her actions, refusing to take her medications, and hiding medications from her mother. For transplant patients, one of the most critical keys to survival is adherence to their medication regimen. Rejection of organs can often occur when patients do not adhere to this regimen (Rodrigue & Zelikovsky, 2009). The consultation-liaison (C/L) psychiatry service was asked to see the patient during her hospitalization to evaluate for depression and to help manage oppositional behaviors. Initially after transplant, she refused to talk or to get out of bed, prompting concern for depression. Her defiance quickly began to hinder the nursing staff's attempts to care for the patient. She exhibited significant oppositional behaviors including yelling, refusing to respond to caregivers' questions, and pleading with nursing staff to avoid activities such as getting out of bed, walking around the unit, and engaging in physical therapy. She became aggressive toward nurses on several occasions when they were attempting to do dressing changes or administer medications. She was also noted to say hurtful things to the nursing staff and to accuse nursing staff of maltreatment. Because of the necessary intensity of her care and the significant problem behaviors, nursing staff were requiring increasing amounts of time to perform their duties for this patient and subsequently had less time for other patients. These interactions also led to a significant decrease in nursing morale. Nurses also reported that they feared being reprimanded for “maltreatment” of the patient.
560 A behavior plan was created by the C/L team in conjunction with the nursing staff with three target goals of (a) taking medications, (b) walking around the unit three times a day, and (c) allowing dressing changes. When compliant with one of these goals, the patient earned stickers that could be exchanged for a “reward” such as computer time, watching a movie, or special time with a staff member doing activities such as manicures. When noncompliant with these target goals or when verbally or physically aggressive, opportunities to earn rewards were withheld, and attention was withdrawn for a brief period unless medically necessary. Several challenges arose during the implementation of this behavior plan, the most significant of which was difficulty establishing consistency. The patient had as many as 30 different nurses and patient care technicians during the week and each caregiver had his or her own style of “parenting.” Some felt that the patient should not be made to walk everyday when she complained of pain, whereas others suspected that her physical complaints were excuses not to comply with her schedule. Some voiced fear of being removed from their duties due to complaints of maltreatment by the patient when staff attempted to adhere to the behavior plan. Several stated that it was easier to allow the patient to be noncompliant with the behavior plan rather than attempt to enforce it. Reinforcing the patient in this way by allowing noncompliance created a type of intermittent reinforcement. Because this patient was reinforced for being noncompliant at times, there was no incentive for her to follow the behavior plan, thus making her behaviors even more difficult to extinguish. In addition to discrepancies between nursing staff enforcement, the patient's mother also presented challenges to following the behavior plan. When the patient's mother was present, she would not withdraw privileges for noncompliance and would instruct nurses that the patient should be allowed to refuse to complete her daily tasks if not feeling well. Nurses were then faced with the dilemma of whether to follow the mother's instructions or adhere to the behavior plan. When the patient was physically aggressive toward nursing staff, her mother questioned what had been done to her to provoke this response and did not give the patient consequences for her behavior. Implementation of this behavior plan also encountered resistance from the medical service who was not familiar with the diagnosis or implications of ODD. On several occasions, the medical team allowed the patient to be excused from completing her daily tasks if she offered resistance to the nursing staff. This reinforced the patient's actions and prompted greater refusal the next time she was required to do a task. Multiple meetings were convened with nursing staff, ancillary medical staff (including patient care technicians, child life specialists, social work, and chaplaincy), and the C/L psychiatry service to determine how best to help this patient. It became clear that the medical staff caring for the patient would benefit from additional education on symptoms and management of ODD as parents are educated
A.M. Kledzik et al. in the outpatient setting. Two separate 3-hour training sessions were organized to educate nurses, child life personnel, and occupational and physical therapists in how to manage oppositional behaviors. This training was based on Dr. Russell Barkley's extensive work with oppositional and defiant children (Barkley, 1997). The first portion of the training session consisted of an informative discussion on symptoms of ODD and management techniques, including reward systems to increase desired behaviors and appropriate consequences for noncompliance. The second portion of the training involved a role-play with a mock patient who simulated typical behaviors of this patient on the medical unit, as well as the most common problematic interactions with nursing staff (i.e., when the patient engaged in complaining or stalling behaviors, the nurses practiced active ignoring and matter-of-fact interactions). The patient's mother was also given the opportunity to participate in behavioral management training to ensure that the behavior plan would continue to be implemented at home after discharge. The patient's mother was able to practice using these skills in the inpatient setting while receiving feedback and guidance from the C/L psychiatry team. In follow-up meetings with staff, direct care nurses reported feeling empowered to care for this patient and as having necessary tools to perform their duties. By using techniques learned in the training session, nurses were able to decrease time spent persuading the patient to comply and subsequently reported more positive interactions, both with the patient and her mother. The nursing staff reported that the patient's mood substantially improved, and she was more polite with requests and engaged in less disrespectful behavior. As the patient's hospitalization was further prolonged by medical complications, medical staff became less consistent with the behavior plan, and the patient's previous disruptive and oppositional behaviors resurfaced at a level of severity equivalent to that seen prior to training. As a result, the C/L psychiatry team met with nursing supervisors to create additional training opportunities for staff, including reviewing didactic material, identifying nurses to model appropriate interventions for other staff, and encouraging the patient's mother to enforce the plan when the patient was in her care. Following further training, the patient's problematic behavior again decreased until the time of her discharge. Outpatient follow-up was arranged to ensure that the patient's mother continued to have support and guidance regarding behavior modification strategies after her child's discharge.
Discussion As illustrated in the case above, there are several key issues when treating ODD in the pediatric medical setting. Because of the large number of caregivers involved in the treatment of such a patient, ensuring consistency with a behavior plan can be challenging. In the outpatient setting, therapists typically have to gain buy-in from only two
Challenges in Treating Oppositional Defiant Disorder in a Pediatric Population caregivers, the child's parents or guardians. In the hospital setting, as illustrated above, different “parenting” styles of up to 30 caregivers can complicate the therapeutic approach. Providing comprehensive training for all those participating in the direct care of the patient can be an effective way of enhancing consistency with behavior modification strategies. Another complicating factor is the child's medical illness. Often, caregivers are reluctant to enforce discipline strategies because the child is ill, thereby unwittingly reinforcing and eventually worsening behaviors. In our experience, balancing empathy for a child's physical symptoms with behavior modification of oppositional symptoms can be a difficult task. Parents often become more lenient with negative behaviors when a child is ill, which can lead to more significant problems once the illness resolves (Wells, 2003). Open communication between the medical team, nursing staff, and parents can help to determine when a child is too ill to comply with behavioral expectations. Typically, even when extremely ill, a child should still be expected to maintain a level of respect for those around her, and it should be emphasized that physical aggression is never acceptable. It is important to have the parents participate in the day-today management of ODD while the child is hospitalized to ensure continued adherence after discharge.
Ethical Considerations As illustrated in the case above, the presence of oppositional and defiant behaviors can have life-threatening consequences when the child also has a serious medical condition. Pediatric transplant patients have been found to have up to a 40% nonadherence rate with their treatment regimens due to problems with forgetfulness, side effects, and financial pressures related to paying for medications (Berquist et al., 2006). When these problems coexist with oppositional and defiant behaviors, the nonadherence rate can further increase. As a result, it is essential that during pretransplant evaluations, evaluators conduct a thorough psychosocial assessment to elucidate any potential problems or areas of concern. Both parents and medical staff should receive training to address factors that increase nonadherence, including behaviors such as oppositionality and defiance. All members of the treatment team should receive this training, and the treatment regimen should include regular evaluation of progress and trouble-shooting of problems that arise. A list of references for providers is provided below.
Future Directions Further directions for study include objective measures of the effectiveness of training sessions, both in terms of decreasing oppositional and defiant behaviors and improving
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caregivers' adherence to the behavior plan, consistency among caregivers, and morale of nursing staff. Pharmacologic treatment of aggressive and defiant behaviors should also be an area of investigation, especially in terms of drug interactions with other medications and when to initiate medications in addition to behavioral techniques.
Additional Resources for Nurses and Parents Websites:American Academy of Child and Adolescent Psychiatry: http: //www.aacap.org/cs/ODD.ResourceCenter#AboutODD. American Academy of Pediatrics http://www.healthychildren.org/English/health-issues/conditions/adhd/pages/Behavior-Therapy-ParentTraining.aspx. Mayo Clinic: http://www.mayoclinic.com/health/oppositional-defiantdisorder/DS00630. Books:Barkley, R. A., & Benton, C. M. (1998). Your defiant child: Eight steps to better behavior. New York, NY: The Guilford Press. Kazdin, A. E. (2009). The Kazdin method for parenting the defiant child. New York, NY: Houghton Mifflin. Phelan, T. (2010). 1,2,3 Magic: Effective discipline for children 2–12 (advice on parenting). Glen Ellyn, IL: ParentMagic, Inc.
Acknowledgments There are no financial disclosures to make.
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