Treatment of Behavioral Disorders - Case Study Example

Case Study of Behavioral Disorders by Male Vignette Joe, a thirteen-year-old Asian-American boy, is enrolled in ninth grade at a public high school located in the inner city of a large metropolitan area. Since kindergarten, his teachers have reported increasing levels of concern about his behavior. In elementary school, he was described by his teachers as immature and argumentative with authority figures. In middle school, his behavior escalated to include verbal and physical aggression toward classmates. Recent reports indicate that he disrupts the classroom often by arguing with his teacher, talking excessively and loudly, and disobeying classroom rules. During breaks or when outside the classroom, Joe associates with a group of boys who tend to get into trouble. He tends to become angry often and easily and has gotten into many fights. Some of his classmates have reported that Joe has threatened them. He does not seem to feel guilty when he gets into trouble. He rarely finishes his schoolwork and is getting poor grades. Beginning this year, Joe’s teacher has reported that he seems easily distracted. Testing completed by the school psychologist indicates that Joe is intelligent and creative. Results do not support the presence of a learning disability or a developmental disability. The school psychologist indicates that Joe lacks sufficient motivation or desire to complete his work thoroughly or carefully. Joe’s parents report that he refuses to follow rules at home, is often angry, and tends to blame his siblings when he gets into trouble Joe, a thirteen-year old boy may have oppositional defiant disorder or conduct disorder. According to APA diagnostic criteria, oppositional defiant disorder may be applied as Joe is reported to lose temper easily, act provokingly regarding others, and violate social norms. The sum of these criteria may signify OOD. Joe has problems with academic performance and social adjustment, and is involved into a company of young men who get into trouble. Joe also refuses to stick to the norms and rules set at school and at home (ODD, 2014). Oppositional defiant disorder may be confused with conduct disorder as many symptoms of these two mental disorders are common. Joe is described as an aggressive boy, who is threatening his classmates and fighting often. His habit to blame others for his faults may also be regarded as a symptom. Conduct disorder is characterized by aggression to people and animals (bullying, threatening, and fighting), deliberate destruction of property, deceitfulness or theft (blaming others for personal faults, stealing things of non-trivial values and others, breaking into houses and cars), serious violation of norms and rules (Conduct Disorder, 2014). I consider oppositional defiant disorder to be more likely in Joe`s case than conduct disorder because to classify CD three criteria out of four have to be persistent and repetitive in a child`s behavior. Joe acts aggressively, fights and threatens, cons his friends and has poor academic performance, but he was not reported to violate rules seriously (truancy or escapism from home) and did not have cases of property damage. It was reported that Joe`s provoking and disobedient behavior in primary school has escalated to verbal and physical aggression which can be connected to teenage period and bad company. The boy seems to like being involved into a company, which gets into troubles and fights often. It is possible to conclude that his aggressiveness increases with age. The difficulty with diagnostics is that it is not clear for how long such symptoms as aggression and deceitfulness were marked in the child`s behavior as the term “recently” describes the time frame too vaguely. A child with ODD loses temper easily, often has conflicts with adults, refuses to obey, and often irritates people intentionally. He also blames other people in his faults, is often angry and resentful, spiteful, and vindictive. All these characteristic are pertinent to Joe`s behavior (ODD Criteria, APA, 2013). Children with oppositional defiant disorder confront their primary caregivers and the authoritative figures in their surroundings. Children can ignore their parents and can disobey and reject requests, prohibitions, and concerns of elder people intentionally (Mathys & Lochman, 2008). They are prone to act aggressively towards others. It presupposes hitting, fighting, bullying, mocking other children on purpose. Children with ODD often have antisocial behavior, which means that they violate rules and norms easily. Hare marks that patients with ODD often have psychopathic features of personality, such as lack of guilt and empathy, inability to form lasting relationship (1993). These symptoms also suggest oppositional defiance disorder in Joe as he does not seem to feel guilt when he gets in trouble. The children diagnosed with ODD have disruptive behavior, which means that they can interrupt others and do not like waiting. The accurate reasons of oppositional defiance disorder appearance in children are unknown, however, a number of social, biological, and psychological factors contribute to its progressing. Among the biological factors it is possible to distinguish heredity. A child with a parent who suffers from ADHD, ODD, and CD is more likely to be diagnosed with the disorder as well. If parents have history of substances abuse, depression, chemical brain imbalance it puts their children at risk as well. eAACAP admits that bad relationship between a child and parents or a child negligence also influences probability of a child to have ODD. Social factors include family instability, bad discipline, poverty, abuse, and chaotic upbringing (eAACAP guide, 2009). There is no universal treatment of ODD to be applied, and the treatment plan should be elaborated personally for each case. Treatment may last from several months to several years. Among the most effective practices eAACAP names family therapy, cognitive problem-solving skills training, social skills programs in schools, and medication therapy. Parents consulting and education is optimal for pre-school children and consists of educating parents how to cope with provoking children`s behavior in an optimal way. This way of treatment is considered to be one of the most effective. For school children with ODD parental training alongside with teachers involvement is more productive. School-based training aimed to teach children how to control their behavior and react according to situation. Medication therapy proves to be ineffective if utilized without parental or children reeducation. However, in some cases drugs can alleviate the symptoms of the ODD if it is diagnosed with ADHD. Thus, in order to receive the best result it ODD treatment it is necessary to reveal all the concomitant disorders, such as CD or ADHD (Brestan & Eyberg, 1998). It is crucial to notice that one of the most ineffective ways of ODD treatment is forcing children to act in a certain way. Frightening children or making them behave as a “normal child” may only increase aggressiveness in children and lead to symptoms progressing (eAACAB, 2009). ODD is sometimes perceived as milder form of CD (Rowe et al., 2010). According to DSM-IV some characteristics of ODD are also present in CD diagnostics, however, there is still no direct evidence suggesting ODD and CD interdependence. ODD is still regarded as disputable diagnosis as some researches are prone to consider it to be acceptable rebellious conduct within temperamental violations but not a mental disorder as it is (Rowe et al., 2010). Many symptoms of ODD coincide with attention deficit hyperactivity disorder, which makes diagnostics even more complicated (Rowe et al., 2010) Female Vignette Maria is an eight-year-old daughter of Mexican-American parents who recently immigrated to the United States. They speak some English, and Maria is fluent in both English and Spanish. She is enrolled in third grade at the local public elementary school. Since second grade, her parents have reported concerns about her difficulty in paying attention or maintaining her concentration. They indicate that she has significant difficulty in completing her homework because she daydreams and is easily distracted by sounds and activities in the home. Maria has the same problem in the classroom, so she often has to bring unfinished classroom work home to complete. Maria gets frustrated at school and during homework time, often stating that she “can’t do” the work and referring to herself as “dumb” or “not smart enough.” Maria’s frustration with her schoolwork has led to some irritability lately, as well as some desire to avoid school. She tends to have more of a temper at home recently and expresses hopelessness at times. She is most content playing soccer or video games. She tends to concentrate very well during those activities. Standardized testing completed by all children in the third grade indicates that Maria is of average intelligence. Screening by the school psychologist indicated that she most likely does not have a learning disability. Maria is most likely to have attention deficit hyperactivity disorder or oppositional defiant disorder as they both are classified according to DSM-IV-TR in the common subcategory of Attention-Deficit and Disruptive Behavior Disorders. Maria`s frustration, irritability, and easy loss of temper may suggest ODD, however, her inability to concentrate on subjects, daydreaming, frustration as well as her possibility to concentrate on video games and volleyball signify ADHD. Moreover, Maria has almost all factors suggesting inattention and several factors suggesting hyperactivity/impulsivity. Maria`s symptoms persist for more than 6 months as her parents have reported concerns about her difficulty in paying attention or maintaining her concentration since second grade . According to APA classification, attention deficit/hyperactivity disorder can be described in terms of inattention, hyperactivity/impulsivity, and impulsivity. Inattention diagnosed if six or more of the following symptoms are observed more than a half a year. If a child is not able to concentrate on details and stick to one plan for a long time, seems absent-minded when he/she is supposed to listen to someone, is unable to sustain the task, is not able to follow instruction or finish pre-planned task, escapes from doing homework, is prone to lose things, is forgetful, and distracted by the environment, he or she most likely has attention deficit hyperactivity disorder. Hyperactivity/impulsivity is also proven if six of the following symptoms remain for more than 6 months: fidgeting with hands and squirming in the seat, leaving seat without permission, redundant climbing or running, engaging in entertainment activities with much noise, acting as if “on the go”, and talking too much. The children diagnosed with impulsivity have problems with waiting for their turn and keeping quiet while someone else is speaking (Diagnostic criteria AHDH, 2010). Attention disorder is mainly used as umbrella term, however the term “ADHD symptoms” refer mostly to hyperactive, inattentive, and impulsive behavioral patterns. ADHD can be utilized only with regard to children, its usage for adults’ diagnostics is inappropriate. In order to diagnose ADHD in children a doctor has to interview his/her parents, teachers, and examine the child carefully. Crucial factor for AHDH defining is not only symptoms existence in children for a persuasive amount of time, but also their influence on social, academic impairment (Diagnosing of ADHH, 2009). According to Thapar et al., there is no unique reason that can explain AHDH appearance in children. The factors influencing ADHD are inherited as well as non-inherited. Children having relatives with ADHD are at the highest risk of having this mental disorder, thus, genetic factor proves to be the most inflential. There is no direct evidence that such disorders as autism or neurodevelopmental problems overlap with ADHD (2013). Environmental factors such as toxicity, infections, malnutrition, endocrine diseases may have influence on ADHD appearance but to lower extent. Drug and alcohol abuse during pregnancy may have slight effect on ADHD in children. Biological factors may also affect ADHD appearance in children as a number of dopamine-transmitting genes are involved (Milichap, 2010). Treatment of children with attention deficit hyperactivity disorder includes psychotherapy, parental education, school intervention, and medication. For pre-school children parental trainings are the only recommended treatment. They usually include educating parents on the children with ADHD management. Along with school intervention and behavioral therapy these ways of treatment are considered the primary for children treatment. However, they have short –term effects, there are reports, which prove that drugs prescription without psychological help may be ineffective. For drug treatment prescription a child must undergo thorough examination as there may appear side effects. Taking into account a number of factors such as coexisting conditions presence, side effects, and patient preference, the child or young person may be offered methylphenidate, atomoxetine or dexamfetamine. One of the minuses of these drugs is the necessity to take them several times a day (as they are active for about 4 hours). Methylphenidate with longer action (up to 12 hours) has appeared recently. Extra care in prescribing stimulators to children is necessary as a number of researches showed that high doses (for example, more than 60 mg of Methylphenidate) or the wrong application cause accustoming and can induce teenagers to seek for higher doses for achievement of drug effect (Swanson et al., 1998). Attention deficit hyperactivity disorder is one of the most doubtful and disputable mental disorders in modern psychotherapy. AHDH and its treatment are put into question at least from 1970-s. Many doctors, teachers, high-ranking politicians, parents, and mass media doubt AHDH existence. The range of opinions on AHDH is quite wide — from those who do not believe that this mental disorder exists, to those who believe that there are genetic or physiological prerequisites of this state. The committee on children rights of the United Nations reacting to the increased nember of AHDH cases published recommendations where the following was stated: "The committee expresses concern in data that AHDH is diagnosed erroneously and that as a result an increased number of stimulators is prescribed to children despite a number of certificates of harmful effects of these medications. The committee recommends to conduct further researches concerning diagnostics and treatment of AHDH, including possible negative effects of psychostimulants on physical and psychological wellbeing of children, and to use other forms of treatment of behavioral disorders" (UN Nations concern, 2012). According to Foreman, insufficient clarity of AHDH appearance reasons and changes in criteria of diagnosis lead to permanent confusion in scientific and non-scientific circles. Ethical and legal problems concerning treatment were the main areas of disagreements, especially psychostimulants prescription for treatment and their advertising by the groups and individuals who receive money from the pharmaceutical companies. Professional physicians and news agencies claimed that the diagnosis and treatment of this frustration deserves more careful investigation. There also exist a number of theories aimed to explain the reasons of AHDH, such as Hunter vs farmer theory), neurodiversity theory and Social construct theory of ADHD. Some persons and groups deny AHDH existence; however, the majority of medical institutions in the USA consider AHDH diagnoses legitimate. References Brestan, E., & Eyber, S. (1998). Effective psychosocial treatment of conduct-disordered children and adolescents,Clinical Child Psychology, 27, 180-189. Diagnostic criteria for ODD, CD, and ADHD. (2010). Disorders. Retrieved from: http://behavenet.com/node/21488 ADHD. 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Developmental pathways in Oppositional Defiant Disorder and Conduct Disorder, Journal of Abnormal Psychology, 119(4), 726-738. Thapar, A., Cooper, M., & Langley, K. (2013). Practitioner Review: What have we learnt about the causes of ADHD?, Child Psychological Psychiatry, 54(1), 3-16. Swanson, J., Gupta, S., Guinta, D., Flynn, D., Alger, D., Lenner, D., Williams, L., Shoulson, I., Wigal, S. (1998). Acute tolerance to methylphenidate in the treatment of attention deficit hyperactivity disorder in children, Clinical Pharmacology & Therapeutics, 66, 295–305; United Nations Expresses Concern Regarding Australias Over-Prescription of ADD and ADHD Drugs to Children, (2012). UN Nations Report. Retrieved from: http://cchr.org.au/media-releases/257-united-nations-expresses-concern-regarding-australias-over-prescription-of-add-and-adhd-drugs-to-children Read More