Psychiatric Diagnosis and Management: Child Essay

Psychiatric Diagnosis and Management: Child Essay

The patient shows the characteristics of oppositional defiant disorder. She presents with a consistent and frequent pattern of argumentative/defiant behaviors, particularly “arguing with authority figures, actively defying/refusing to comply with requests or rules, deliberately pushing buttons and blames others for her mistakes and behaviors.” The criterion for diagnosis is the presence of the behaviors in at least two settings, home, and school environment, which she meets (Burke & Romano-Verthelyi, 2018). Also, her mother notes the patient exhibited disruptive behaviors from the age of four, being unable to comply with rules at bedtime, which meets the criterion of having at least six months of the mentioned presentations. Her previous and current learning institutions ask for psychiatric evaluations to assess her behavior. During her interview with the psychiatrist, she shows frustration and disrespect to the provider, exhibiting a more severe case where the symptoms are present in interactions with other adults whom the child does not know well.

Currently, pharmacological therapy for oppositional defiant behavior is non-existent. The most appropriate interventions in improving neurodevelopmental outcomes in patients with ODD involve enhancing social skills and problem-solving skills. Child-centered interventions focused on interactions with peers and authority figures alleviates impulsive and aggressive behaviors. Such programs include the Anger Coping Program, and the Problem-Solving Skills training, which train children to slow down their impulsivity and think about challenging situations (Goertz-Dorten et al., 2017). In addition, parent management training has yielded positive outcomes in mitigating the stressors of family life. The training entails imparting specific skills, including handling negative behaviors and promoting desirable behaviors (Dulcan, 2018). The cognitive-based interventions effectively minimize the severity and persistence of defiant, aggressive interactions and improve parental symptoms such as anxiety and depression (Katzmann et al., 2018).

References

Burke, J. D., & Romano-Verthelyi, A. M. (2018). Oppositional defiant disorder. In Developmental Pathways to Disruptive, Impulse-Control and Conduct Disorders (pp. 21-52). Academic Press. https://www.sciencedirect.com/science/article/pii/B978012811323300002X

Dulcan, M., Ballard, R., Jha, P., Sadhu, J. (2018). A concise guide to child & adolescent psychiatry 5^th ed). American Psychiatric Association Publishing.

Goertz-Dorten, A., Benesch, C., Hautmann, C., Berk-Pawlitzek, E., Faber, M., Lindenschmidt, T., Stadermann, R., Schuh, L., & Doepfner, M. (2017). Efficacy of an individualized social competence training for children with Oppositional Defiant Disorders/Conduct Disorders. Psychotherapy Research, 27(3), 326–337. https://doi.org/10.1080/10503307.2015.1094587

Katzmann, J., Görtz-Dorten, A., & Döpfner, M. (2018). Child-based treatment of oppositional defiant disorder: mediating effects on parental depression, anxiety, and stress. European Child & Adolescent Psychiatry, 27(9), 1181–1192. https://doi.org/10.1007/s00787-018-1181-5

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Laura Brewer 

Laura Brewer

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Case Study Response – Module 6

Differential Diagnosis

1. Oppositional Defiant Disorder – Characterized by a pattern of anger, irritability, argumentative/defiant behavior, and/or vindictiveness. Symptoms occur over at least a six month period and must include at least four of the following with someone other than a sibling: often loses temper, often touchy or easily annoyed, often angry and resentful, often argues with authority figures or adults, often defies or refuses to comply with requests and rules, often deliberately annoys others, often blames others for mistakes or behaviors, has been spiteful or vindictive (APA, 2013). The age of the patient (9 years) requires that the symptomatic behavior occurs at least once per week for at least six months. Impairment in social or school function should be present. Carefully consider frequency and intensity of behaviors to determine if they are inappropriate for developmental level, gender, and culture (APA, 2013).
2. Intermittent Explosive Disorder – Characterized by recurrent behavioral outbursts that represent a failure to control aggressive impulses (APA, 2013). Verbal or physical aggression occurring twice weekly for a period of three months, or three behavioral outburst involving destruction to property or physical assault to animals or persons indicate consideration for intermittent explosive disorder (APA, 2013). The patient must be at least six years old with the magnitude of aggressiveness out of proportion to the perceived cause or stressor. Premeditation is not present and recurrent outbursts cause suboptimal functioning (APA, 2013).
3. Conduct Disorder – Characterized by a repetitive and persistent pattern of behaviors that violence the basic rights of others and includes at least three of the following over the last 12 months: Bullies/threatens/intimidates, initiates physical fights, uses a weapon to cause serious physical harm, physically cruel to people, physically cruel to animals, stolen during a confrontation, forced someone into sexual activity, engaged in fire setting with intent to create serious harm, deliberately destroyed other’s property, broken into a house/car/building, lies to obtain things or avoid obligations, stolen items of nontrivial value without confrontation, stays out at night despite parental rules, run away from home overnight at least twice, is often truant from school before 13 years of age (APA, 2013). Criteria not met.Would require specifier childhood-onset type due to patient age.
4. Attention-deficit/hyperactivity Disorder (ADHD) – Often found to be comorbid with disruptive, impulse-control, and conduct disorders.ODD occurs in up to 60% of patients diagnosed with ADHD (Noordermeer et al., 2017). Patient needs careful assessment to determine whether a comorbid disorder is present.
5. Intellectual Disability –Ruled out with neuropsychiatric testing revealing a normal IQ.

Discussion

            The patient in this case study meets the criteria for Oppositional Defiant Disorder. Her presentation shows a consistent and frequent pattern of argumentative/defiant behaviors, specifically “arguing with authority figures, actively defying or refusing to comply with requests or rules, deliberately pushing buttons, and blames others for her mistakes and behaviors”. The behaviors are present in at least two settings, both school and home environments. A time period of at least six month’s worth of behaviors exists, with the mother noting that the patient has exhibited disruptive behaviors as early as age four with inability to follow rules at bedtime. Although that specific example could represent a developmentally appropriate behavior for a four year old, there is also a history of her schools asking for psychiatric evaluations to assess behavior. When interviewing the patient during the appointment, it’s noted that the patient becomes frustrated and disrespectful with the provider, indicating a more severe case where the symptoms are also evident in interactions with adults that the child does not know well (APA, 2013).  

            This case study notes that the patient has a father who is incarcerated for assault and also reveals that her home life with her mother and siblings (now out of state) may not have been a consistent, stable environment. A background of experiences with hostile parenting can contribute to a child’s disposition towards oppositional defiant disorder (APA, 2013). Parental risk factors exist in this instance. Parental psychopathology is an important factor in children diagnosed with ODD with maternal stress levels significantly impacting externalizing behaviors (Katzmann et al., 2018). Research indicates a bidirectional flow of influence between the parent and child, each with profound implications for the resulting outcomes (Katzmann et al., 2018).

Management Plan

There is no evidence-based pharmacological intervention for ODD (Dulcan, 2018). The interventions that have proven the most effective in improving neurodevelopmental outcomes of patients with ODD are associated with building social skills and problem-solving skills (Dulcan, 2018). Child-based interventions focusing on interactions with both peers and authority figures provides reduction in impulsive and aggressive behaviors (Goertz-Dorten et al., 2017). Examples of programs currently being utilized are the Anger Coping Program, and the Problem-Solving Skills training, both of which teach participants to slow down their impulsivity and think through challenging situations (Goertz-Dorten et al., 2017).

Additionally, parent management training has proven successful in mitigating the stressors of family life and includes teaching specific skills such as dealing with negative behaviors and promoting desired behaviors (Dulcan, 2018). These cognitive based interventions can reduce the persistence and severity of defiant, aggressive interactions and in turn improve parental symptoms such as depression and anxiety (Katzmann et al., 2018).

ODD is frequently comorbid with ADHD, a commonly diagnosed psychiatric disorder in children (Noordermeer et al., 2017). Concurring ODD and ADHD reduces the likelihood for positive developmental outcomes and often results in an increased risk of developing anxiety, depression, and antisocial personality disorder later in life (Noordermeer et al., 2017). Thorough assessment for ADHD characteristics should be completed with multiple environments (both home and school) being evaluated (Noordermeer et al., 2017). Connor’s Teacher Rating Scale can be completed by school staff to aid in assessment of symptoms affecting functionality (Noordermeer et al., 2017). If ADHD is diagnosed, the patient will benefit from psychopharmacological interventions to manage symptoms, reduce impulsivity, and assist with self-regulation.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Dulcan, M., Ballard, R., Jha, P., Sadhu, J. (2018). Concise guide to child & adolescent psychiatry 5^th ed). American Psychiatric Association Publushing.

Goertz-Dorten, A., Benesch, C., Hautmann, C., Berk-Pawlitzek, E., Faber, M., Lindenschmidt, T., Stadermann, R., Schuh, L., & Doepfner, M. (2017). Efficacy of an individualized social competence training for children with Oppositional Defiant Disorders/Conduct Disorders. Psychotherapy Research, 27(3), 326–337. https://doi.org/10.1080/10503307.2015.1094587

Katzmann, J., Görtz-Dorten, A., & Döpfner, M. (2018). Child-based treatment of oppositional defiant disorder: mediating effects on parental depression, anxiety and stress. European Child & Adolescent Psychiatry, 27(9), 1181–1192. https://doi.org/10.1007/s00787-018-1181-5

Noordermeer, S., Luman, M., Weeda, W., Buitelaar, J., Richards, J., Hartman, C., Hoekstra, P., Franke, B., Heslenfeld, D., & Oosterlaan, J. (2017). Risk factors for comorbid oppositional defiant disorder in attention-deficit/hyperactivity disorder. European Child & Adolescent Psychiatry, 26(10), 1155–1164. https://doi.org/10.1007/s00787-017-0972-4

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