Running Head: OPPISITIONAL DEFIANT DISORDER 1

Transcription

1 Running Head: OPPISITIONAL DEFIANT DISORDER 1 Oppositional Defiant Disorder Treatment Plan Katie King Western Carolina University Recreational Therapy Debbie Logan

2 OPPISITIONAL DEFIANT DISORDER 2 Definition Oppositional Defiant Disorder is defined as a persistent pattern of negative, disobedient, hostile, and defiant behaviors towards others, typically towards those of an authority figure (Lindhiem, Bennett, Hipwell, & Pardini, 2015). The Diagnostic and Statistical Manual of Mental Disorders in the 5 th edition, or the DSM-5, is a book that contains information about all of the different mental health disorders. The DSM-5 defines Oppositional Defiant Disorder as, A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four and exhibited during interaction with at least one individual who is not a sibling (American Psychiatric Association, 2013, para.1). Individuals with ODD have a tendency to act out towards people of authority such as parents, teachers, or other individuals who possess higher authority. Individuals with ODD will often display a continuous angry or irritable mood; this may be displayed through the loss of tempers, annoyance, or resentfulness (American Psychiatric Association, 2013). Behavioral examples of ODD would include acts such as refusing to follow rules, blaming others for one s own mistakes, intentionally annoying others, and easily becoming annoyed by others (Behavior or conduct problems, 2016). Studies have shown that youth with ODD have been shown to have colorations with self-esteem, frustration tolerance, and even substance use and abuse (Cederna-Meko, Koch, & Wall, 2014). Demographic Information Oppositional Defiant Disorder has a prevalence rate ranging from 1% - 11% of children affected by it (American Psychiatric Association, 2013). The disorder is more prevalent in males, with a four to one ratio (American Psychiatric Association, 2013). Oppositional Defiant Disorder, or ODD, is typically diagnosed before the age of eight, but no later than the age of

3 OPPISITIONAL DEFIANT DISORDER 3 twelve (Behavior or conduct problems, 2016). Home life can often serve as a precursor to ODD. Children who grow up in households where there is a disturbance in the care given to them are more likely to have ODD. For example, a child who loses a parent or guardian or does not have a persistent caregiver may be more likely to suffer ODD. Other conditions often include inconsistent, harsh, abusive or neglectful practices (Behavior or conduct problems, 2016). Conditions such as attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) are the two most common disorders that co-occur with Oppositional Defiant Disorder (Behavior or conduct problems, 2016). Strengths of Client April has a positive relationship with her former guardians and grandparents to which she refers to as mawmaw and pawpaw. This is a strength for this client because her relationship with her grandparents is a positive aspect in her life and can be used as a motivation with her treatment plan. While in school, April was involved with horses. She indicated that she participated in horse-racing. April currently participates in equine therapy and in interested in becoming a veterinarian and wants to work more specifically with horses. This goal that she has set for herself will also be a good motivation for her. April s is a very intelligent and self-aware girl. Prior to being admitted into the psychiatric facility, April had tested an IQ score of 120 which is above normal. This is definitely a strength and will open a lot of doors for April for her future. April has a good scene of humor and is very creative. She responds positively to art and animals, horses in particular, and she has exceptional fine and gross motor skills. Needs of Client April s most urgent needs are those relating to her Oppositional Defiant Disorder. These need to include:

4 OPPISITIONAL DEFIANT DISORDER 4 April needs to work on her anger management and her erratic moods. Negative, disobedient, hostile, and defiant behaviors towards others are typical behaviors of individuals with ODD (Lindhiem, Bennett, Hipwell, & Pardini, 2015). April need to improve her coping skills and managing her emotions which may help her with other aspects of her life as well. It is typical for individuals with ODD to not have very good coping skills to help them with their emotions (American Psychiatric Association, 2013). April needs to become more compliant and respectful towards authority figures. It is normal for individuals with ODD to act in angry, irritable, and defiant attitudes towards people of authority (American Psychiatric Association, 2013). April needs to adapt to her family barriers because she has had a disturbance in her at home life which most likely is the cause of her ODD. A disturbance in care at a young age is typically a precursor to ODD (Cederna-Meko, Koch, & Wall, 2014). Environmental Barriers Living in a long-term psychiatric facility is a barrier for April because she may feel closed off to the rest of the word due to her location and her time spent in the facility may have an effect on the degree of her disorder (Stellwagen & Kerig, 2010). April is currently in the custody of DCS. April could potentially be separated form her existing family members and placed into foster care (Cederna-Meko, Koch, & Wall, 2014). Cultural Information Non-traditional household; raised by grandparents.

5 OPPISITIONAL DEFIANT DISORDER 5 She is a female and ODD is typically less common in females (American Psychiatric Association, 2013). April is 16 years old. She was hospitalized at the age of 14 which is relatively late for a diagnosis of ODD (Behavior or conduct problems, 2016). Her history of sexual abuse may indicate a potential distrust of men (American Psychiatric Association, 2013). Efficacy Research Johansen, S. G., Arfwedson Wang, C. E., & Binder, P. (2016). Facilitating change in a client's dysfunctional behavioural pattern with horse-aided psychotherapy. A case study. Counselling & Psychotherapy Research, 16(3), doi: /capr Summary This article discusses a study that was done to analyze the impacts of a therapeutic interaction between horses and individuals with behavioral health issues. The idea of the experiment is that the client s interactions with the horse will be relatable to reactions with other individuals. Horses are highly sensitive animals and are very responsive to body language. The hypotheses is that the therapeutic interaction between the client and horse will aid in the client s self awareness and relationship skills. 2 Subjects and Methods The individual in the study was a girl named Anna who suffered from relational problems, social anxiety, and depression. Through equine therapy, Anna became more aware of her emotions and her body expressions.

6 OPPISITIONAL DEFIANT DISORDER 6 Anna participated in a total of 10 therapy sessions. Each session lasted for approximately 60 minutes, once a week, and was followed by a 30-minute reflection of the session. To track Anna s improvements, she was given small interviews after each therapy session. During her third session, Anna was filmed performing activities with the horse in the arena. Afterwards, another interview was conducted. During the interview, Anna was asked questions about how she felt during the riding session such as how certain tasks made her feel. One of Anna s psychological goals was to improve her assertiveness and communication through her body language. To work on this, she would preform tasks such as moving the horse back and fourth and side to side without touching the horse. She would also lead the horse around without pulling the horse or allowing the horse to pull her. Another goal was to improve her anxiety and fear. To work on this, she would perform task such as cleaning the the horse s hooves, which can be rather scary due to the vulnerable position one is put in to access the horse s feet. She would also ride bare back, which made her rely on her muscles, balance and trust for the horse. Her last goal was to work on touch, body contact, and attachment. To work on this, Anna would be instructed to touch the horse with different areas of her body such has her hands, arms, and face both while on the ground and mounted. 3 Findings and Implications There were four main areas of improvement with the client. The first was that she became more aware of how she expressed her needs. When Anna was leading the horse around, she found that she gave into the horse and allowed the horse to lead her instead. Her therapist made her aware of this and in return Anna was able to adapt her behavior in a constructive manner. Anna was able to gain body awareness. Her negative reactions were reflected by the horse, and Anna was able to pick up on those. She was able to calm down when presented with

7 OPPISITIONAL DEFIANT DISORDER 7 stressful situations and by doing so her horse was calmed as well. Anna worked on her personal boundaries through a variety of tasks. Anna had to do an activity with the horse where a pile of hay was placed in the middle of the arena, and she had to use her body to prevent the horse from eating the hay. Through this, she learned that she did not have the confidence to get close enough to the horse to prevent it from reaching the hay. Lastly, Anna gained emotional awareness. During each session interview, Anna was asked about her feelings and how each activity affected them. Anna learned that she directed her feelings towards others before she did herself. 4 Applications for this Case It was rather challenging to find an article that directly related to my specific case study. There were limited articles that fitted the research requirements that were on equine therapy. Of the ones that worked, non were about oppositional defiant disorder. Despite the different diagnoses between the individual from the article and the individual in my case study, the interventions used in the article can be used for my case study client. If I were the therapist conducting the sessions, I would tweak a few of the interventions and make them more geared towards ODD. I definitely like the use of the horse to make the client aware of their body language. With the article, Anna needed to learn to use more body language and become more aggressive. My case study client, April, needs to do the opposite. April could do the exact same tasks such as leading the horse around the arena, and I would expect her to be over aggressive with the horse. In return, the horse would probably not corporate with her and would give off negative body language as well. The goal would be that April picks up on her negative body language and attitude when the horse does not corporate, and she will be motivated to adapt herself in order to get better results with the horse. The main idea of this article and the

8 OPPISITIONAL DEFIANT DISORDER 8 implantations of equine therapy is that horses require a very unique relationship with their riders. This consist of mutual respect, trust, and appropriate body language. All of these can be therapeutic goals and working with horses is a great and effective way to achieve them. Strengths: Top Three Strengths/Needs Creative Very intelligent Exceptional fine and gross motor skills. Needs: Decrease anger Improve coping skills Increase respect for authority figures. Goals To decrease anger by increasing emotion awareness. To increase coping skills by learning new coping strategies. To increase health by learning more about nutrition and diet. Facility My client, April, will be enrolled in a therapeutic riding program that is apart of Hillwood s Psychiatric Facility, where she is currently a resident. Hillwoods is an inpatient psychiatric facility for girls where April was recently transferred to. The faculty owns its own barn and land for its equine therapy program. The program is available for both residents and non-residents.

9 OPPISITIONAL DEFIANT DISORDER 9 Intervention For my client, I will be using equine therapy as my intervention modality. Equine therapy involves the experiences between individuals and horses. Therapeutic riding has been found to be successful among a variety of ages, abilities, and diagnoses. The frequency of this intervention will occur alt. dieb. Monday through Friday (beginning c Monday) For 12 weeks. The intervention used in the study I researched did a total of 10 therapy sessions. Each session lasted for 60 minutes, and occurred once a week. I believe that the pt. in the study I researched would have benefited more by doing more than just 10 secessions that were fairly spaced out. The scope of this intervention will include a combination of groundwork and mounted work c the pt. and the horse. The pt. will learn skills such as respect, trust, and both verbal and nonverbal communication. Through completing a series of tasks while mounted, the pt. will encounter a variety of stressors, satisfactions, and emotions. The intervention will take place both in the facilities barn and indoor riding arena. The duration of this intervention will occur for one hour during each session. There will be a total of three sessions a week: Monday, Wednesday, and Friday. Each session will be divided into 20 minutes of ground work and 40 minutes of mounted riding. The amount of time dedicated to groundwork may change e.m.p. by CTRS. Objectives Goal: To decrease anger by increasing emotion awareness. 1. Skill Practice Acquisition: During the first three therapeutic riding sessions, cl. with verbalize three emotions she experiences during the session to increase her emotional awareness

10 OPPISITIONAL DEFIANT DISORDER Functional Use of Skill: After each therapeutic riding session, client will identify two emotions she experienced during the session, and what she did well or what she should have done to address them to work on decreasing her anger and increasing her emotional awareness. Progress Note S (Subjective Data): April stated, groundwork is stupid, I just want to ride already. During the mounted portion of the session, pt. said this freaking horse isn t listening to me. O (Objective Data: April s body language implied she was irritated during the groundwork portion of the session. She rushed through the brushing and tacking of her horse Buster. Buster pinned his ears and became irritated with April when she brushed him aggressively and when she flung his saddle on him. During groundwork, April would swing Busters lead-rope, startling him, while smirking. During the ridding portion of the session, April was very rough on the reins, even after being told to loosen them multiple times. A (Analysis): April does not understand the importance of ground work with her horse. Because of this she does not take ground work time seriously. April only seems to care about riding. April gets aggravated with her horse when he does not listen to her, often times he does not listen because she is too forceful with him. April does not realize how her actions and emotions impact her horse P (Plan): April will start doing 30 minutes of ground work and 30 minutes of riding. CTRS will discuss the importance of ground work and developing a good relationship with the horse before riding. CTRS will teach April how her actions affect Buster and how she can get better results from him by controlling her emotions and actions. April will continue to come alt. dieb. Monday through Friday.

11 OPPISITIONAL DEFIANT DISORDER 11 Discharge Plan April is a 16 yo WF and was admitted into Hillwoods Psychiatric Facility s therapeutic riding program. April s main Dx is Oppositional Defiant Disorder. April also had Dx of Type I Diabetes, and Psychotic disorder NOS. Cl. just finished a 12-week program, with three sessions per week lasting 60 minutes each. April s main goal was to decrease anger. Cl. has been responding to treatment plan as CTRS expected. Her displays of frustration at first were anticipated. Over the past 12 weeks, cl. has shown outstanding progress. While performing the instructed tasks, cl. was able to verbalize emotions she felt. When confronted with negative emotions or feelings of anger, cl. was able to control her actions in order to get the desired results form her horse. The concern of Aprils Type 1 Diabetes is still a concern. With written permission, I am going to refer April to Jessica Fox, the registered nutritionist at Hillwood s Psychiatric Facility. Do to clients love for riding, post D/C I am going to offer April a part time positon as a stable hand at the barn so she can continue caring for horses and riding as a leisure activity. Katie King, RT Student 3 December 2017

12 OPPISITIONAL DEFIANT DISORDER 12 References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC, Retrieved from Behavior or conduct problems. (2016). Centers for Disease Control and Prevention, Retrieved on September 10, 2017 from Cederna-Meko, C. C., Koch, S., & Wall, J. (2014). Youth with oppositional defiant disorder at entry into home-based treatment, foster care, and residential treatment. Journal of Child & Family Studies, 23(5), doi: /s y Johansen, S. G., Arfwedson Wang, C. E., & Binder, P. (2016). Facilitating change in a client's dysfunctional behavioural pattern with horse-aided psychotherapy. A case study. Counselling & Psychotherapy Research, 16(3), doi: /capr Lindhiem, O. l., Bennett, C., Hipwell, A., & Pardini, D. (2015). Beyond symptom counts for diagnosing oppositional defiant Disorder and conduct disorder? Journal of Abnormal Child Psychology, 43(7), doi: /s x

13 OPPISITIONAL DEFIANT DISORDER 13 Stellwagen, K. K., & Kerig, P. K. (2010). Relation of callous-unemotional traits to length of stay among youth hospitalized at a state psychiatric inpatient facility. Child Psychiatry and Human Development, 41(3), doi: /s