COURSES ARTICLE - THERAPYTOOLS.US WORKING WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) OPPOSITIONAL DEFIANT DISORDER CONDUCT DISORDER WORKING WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) OPPOSITIONAL DEFIANT DISORDER CONDUCT DISORDER There is somewhat of a continuum and overlap between manifestations of Attention Deficit Hyperactivity Disorder Oppositional Defiant Disorder and Conduct Disorder. ADHD may be an underlying issue in both Oppositional Defiant Disorder and Conduct Disorder. A careful assessment taking this into consideration will allow the therapist to rule out the ADHD diagnosis in these instances. Because of the commonality in behavioral symptoms, the treatment focus and objectives will be offered as a single section to draw from based on the needs of the case. ADHD children are at risk for delinquent behaviors because they do not consistently demonstrate behaviors that will naturally elicit positive reinforcement. Instead they tend to receive negative feedback from their peers and adults. In an effort to fit in with a peer group, they may find acceptance with children adolescents that have obvious behavioral problems. Generally, there is behavioral evidence of difficulties associated with ADHD in all settings (home, work, school, social), and symptoms are usually worse in situations requiring sustained attention. Although the excessive motor activity characterizing ADHD often subsides prior to adolescence, the attention deficit frequently persists. When ADHD is suspected first referral for medical evaluation to rule out any physical factors such as allergies, endocrine problems. Also, rule out mood disorders and abuse. In case of Oppositional Defiant or Conduct disorder characteristics are present rule out substance abuse, sexual abuse, physical or emotional abuse, and ADHD. GOALS for ATTENTION DEFICIT HYPERACTIVITY DISORDER: Â Assess for referral for medication evaluation. Â Enhance patent education regarding familial and clinical aspects of the disorder and behavioral management. Â Collateral cooperation in behavioral management with teaching staff. Â Develop responsible behavior and self-respect. Â Develop appropriate social skills. Â Treatment Focus and Objectives. Â Improve communication. Â Decrease defensiveness. Â Improve self-esteem. Â Improve coping.
 Problem solving.  Improve insight.  Impulse control.  Anger management.  Eliminate potential for violence. Let us review each goal or objective previously reviewed and the essential components that must be focused in treatment: (1-14): Evaluate for Referral for Medication Evaluation: A. If parents have a negative or resistant response to medication, direct them to some appropriate reading material and suggest that they meet with a physician specializing in this disorder before they make a decision Parent Education: A. Overview giving the defining criteria of the specific disorder; explore how the family is affected and how they respond, etiology, developmental influences, prognosis, a selection of reading materials and information on a community support group, if available B. Parent effectiveness training. Training to include parenting skills in behavioral modification, contingency planning, positive reinforcement, appropriate limit setting and consequences, encouraging self-esteem, disciplining in a manner that fosters development of responsibility and respect for others. Consistency is imperative to successful behavioral change and management. C. Explore dysfunctional family dynamics: 1. Explore and identify family roles. 2. Identify modification and changes of person's role in family. 3. Identify the various roles played by family members and the identified patient, and modify or change as needed in accordance with appropriate family dynamics and behavior. 4. Facilitate improved communication. 5. Clarify differences between being a parent and a child in the family System, along with role expectation. 6. Explore the necessity of out of home placement if parents are unable to effectively manage and support behavior change or are actual facilitators of antisocial behaviors. Depending on severity of behaviors, it may require placement for monitoring to prevent risk of harm to self or others. Teachers Role: When working in classroom setting or teachers one must: A. Define classroom rules and expectations B. Break down goals into manageable time frames. Time frames can be flexible to 15 minutes a day or more once a week or more. Break tasks into very small steps, and give constant feedback. C. Give choices whenever possible. D. Provide short exercise breaks between work periods.
E. Use a time to encourage staying on task. If these students finish a task before the allotted time, reinforce their behavior. F. Facilitate the development of social skills. G. Encourage specific behaviors. H. Develop contracts when appropriate. It will also heap parents reinforce the teacher's program: 1. Develop a secret signal that can be used to remind students to stay on task, which will avoid embarrassment and low serif-esteem. J. Facilitate the development of monitoring-monitoring so that students can pace themselves and stay on task, as well as self-reinforce for progress. K. Structure the environment to reduce distracting stimuli. L. Separate these students from peers who may be encouraging inappropriate behavior. M. Highlight or underline important information. N. Use a variety of high-interest modes to communicate effectively (auditory, visual, hands-on, etc.). 0. Position these students dose to resources/sources of information. P. Consistency is imperative. Q. Work collaterally with all professionals to develop an individualized cognitive behavioral program. 4. Lack of Self-Respect and Responsibility Toward Self or Others: A. Have person define these terms accurately (may need support or use of external resources) and compare the working definitions to his/her behavior as well as developing appropriate behavioral changes. B. Facilitate the concept of choices related to consequences, and acceptance of consequences as taking responsibility for one's own actions. C. Have these children identify how they are affected by the behavior of others and how others are affected negatively by their behaviors. Clarify that they only have control over their own behaviors. D. Work with parents to clarify rules, expectations, choices, and consequences. Assess Dysfunctional Social Interaction: A. Role-model appropriate behaviors/responses for a variety of situations and circumstances. Provide situations or vignettes to learn from. B. Provide positive feedback and constructive education about their interaction.
C. Identify manipulative or exploitive interaction. Explore intention behind interaction and give information and reinforcement on how to get needs met appropriately. D. Focus on the positive demonstrations of interaction over negative ones when reinforcing behavioral change. E. Have person identify reasons for inability to form dose interpersonal relationships to increase awareness and to develop choices for change. F. Have person identify behaviors that allow one person to feel close or comfortable with another person versus distancing behaviors. Evaluate Impaired Communication Skills: A. Teach assertive communication skills. B. Encourage appropriate expression of thoughts and feelings. C. Role-model and practice communication responses (verbal and nonverbal) for various situations and circumstances. D. Positive feedback and reinforcement. Assess Defensive Behaviors: A. Increase awareness for defensive tendencies by defining with examples and encouraging the individual to identify similar behaviors of his/her own. B. In a no threatening way, expire with these individuals any past feedback that have been given from others about how others perceive them and what contribute to that perception. C. Focus on positives attributions to encourage positive self-esteem. D. Encourage acceptance of responsibility for one's own behavior. E. Have person identify the relationship between feelings of inadequacy and defensiveness. F. Positive feedback and reinforcement. Assess level of Low Self-Esteem: A. Through a positive therapeutic relationship, be accepting, respectful, and ask often what their views are about issues, affirming the importance of what they to offer. B. Support and encourage appropriate risk taking toward desired goals. C. Encourage their participation in problem solving. D. Reframe mistakes in an effort toward change as an opportunity to learn more benefit from experiences. Encourage taking responsibility for one's own mistake. E. Encourage seif-care behaviors: grooming/hygiene, exercise, no use of substance good nutrition, engaging in appropriate pleasurable activities.
F. Identify self-improvement activities; behavioral change, education, growth experiences. G. Identify and develop healthy, appropriate values. H. Identify strengths and develop a form of daily affirmations for reinforcing positive self-image. I. Identify desired changes. Be sensitive, realistic, and supportive in development shaping changes. J. Facilitate assertive communication and assertive body language. K. Educate about the destructiveness of negative self-talk. L. Create opportunities for person to show his/her abilities. M. Notice examples of ability and point them out. Build on strengths. N. Positively reinforce their efforts and accomplishments. Evaluate Ineffective Coping Skills: A. Provide appropriate physical activity to decrease body tension and offer a positive choice with a sense of well-being. B. Set limits on manipulative behavior and give appropriate consequences. C. Facilitate change in coping by not participating in arguing, debating, excessive explaining, rationalizing, or bargaining with the person. D. If Running away make sure to: 1. Identify the nature and extent of running away. 2. Clarify and interpret the dynamics of running away. 3. Work through the identified dynamics. 4. Facilitate the individual to identify the signs of impending runaway behavior. 5. Facilitate identification and implementation of alternative solutions to running away. E. If Lying history: 1. Identify the nature and extent of lying. 2. Confront lying behavior. Assert the importance of behavior matching what is verbalized. 3. Clarify and interpret the dynamics of lying. 4. Work through the dynamics of lying. 5. Facilitate the development of a behavioral management program for lying. Monitor accurate reporting of information, and encourage the person to make amends to those lied to whenever possible. F. Focus on positive coping efforts. G. Encourage honest, appropriate, and direct expression of emotions.
H. Facilitate the development of being able to delay gratification without resorting to manipulative or acting-out behaviors. I. Have person verbalize alternative, socially acceptable coping skills. Ineffective Problem Solving Skills: A. Encourage the identification of causes of problems and influencing factors. B. Encourage the person to identify needs and goals. Facilitate, with the individual's input, the objectives, expected outcomes, and prioritization of issues. C. Encourage the exploration of alternative solutions. D. Provide opportunities for practicing problem-solving behavior. E. Explore goals, and problem-solve how to reach goals. Poor Insight Skills: A. Increase understanding of relationship between behaviors and consequences. B. Increase understanding of the thoughts/feelings underlying choices made. C. Facilitate problem solving appropriate alternative responses to substitute for negative choices. History of Poor Impulse Control: A. Increase awareness, and give positive feedback when the person is able to demonstrate control. B. Explore alternative ways to express feelings. C. Facilitate the identification of particular behaviors that are causing problems. D. Facilitate identification of methods to delay response and encourage thinking through of various responses with associated consequences. History of Poor Anger Management: A. Identify antecedents and consequences of angry outbursts. B. Facilitate understanding of anger within the normal range of emotions and appropriate responses to feelings of anger. C. Identify issues of anger from the past and facilitate resolution or letting go. D. Identify the difference between anger and rage. E. Identify affect of anger on dose, intimate relationships.
F. Identify role of anger as a coping mechanism or manipulation. G. Facilitate the taking of responsibility for feelings and expressions of anger. H. Problem-solve current issues of anger to resolve conflicts. I. Positive feedback and reinforcement for efforts and accomplishments. Assess Potential for Violence: A. Assess for signs and symptoms of acting out. B. Maintain a safe distance and talk in a calm voice. C. Provide a safe, no threatening environment with a minimum of aversive stimulation. D. Use verbal communication and alternative stress and anger releasers to prevent violent acting Out. E. Evaluate Anger management by: 1. Identify the nature, extent, and precipitants of the aggressive behavior (i.e., is the behavior defensive, etc.). 2. Facilitate identification and increased awareness of the escalators of aggressive behavior. 3. Clarify and interpret the dynamics of aggressive impulses and behavior. 4. Work through the dynamics of aggression. F. Reinforce the use of the skills that the Person has developed. G. Have the Person discuss alternative ways of expressing their emotion appropriately to avoid negative consequences. H. Encourage the individual to verbalize the wish or need to be aggressive rather than to act on the impulse. I. If the Person demonstrates the tolerance of intervention, provide a recreational outlet for aggressive impulses. J. Facilitate the individual to implement alternative actions to aggressive behavior. K. At a later time when the threat of acting out has passed, heap the Person to benefit from the experience by reviewing the circumstances, choices, and different points of possible intervention and what would have been helpful reinforce the person's problem-solving efforts. ADDITIONAL CONSIDERATIONS: Regarding culturally diverse and inner-city dwellers, it is imperative to obtain information on the family and neighborhood: 1. Inquire about the possibility of lead intoxication and malnutrition. 2. Ask about parental abuse of substances and antisocial behavior/personality disorder (including family members and peer reference group). 3. In the culturally diverse, assess the level of cultural tolerance for certain behaviors. 4. Determine if their environment demands physical strength and aggression as survival
factors. 5. What is the impact of social/economic pressures on lying, truancy, stealing, early substance abuse, sexual behavior inconsistent/absent parental figures (i.e., single parent who works and is not available), and their values/beliefs. Disorders of behavior are treated with a focus on behavioral interventions. Therefore, when providing therapy provide this features: 1. Highly structured. 2. Moderate in supportiveness (some attention to past patterns/difficulties). 3. May include modalities of individual, family, and self-help groups. 4. Physical examination with minimal use of medication (not a substitute for modifying inappropriate behavior). 5. Brief duration of treatment. Many children diagnosed with Attention Deficit Disorder (ADD), ADHD, or other behavioral disorders may actually be manic depressive. Bipolar Disorder in children: 1. May strike as early as age 7. 2. May be prone to rapid cycling. 3. May go untreated for years. Similarities between hyperactivity and mania in children are that the children are: 1. Excessively active. 2. Irritable. 3. Easily distracted. However children with Bipolar Disorder also exhibit. 1. Elated mood. 2. Inappropriate laughter. 3. Grandiosity. 4. Flights of ideas. 5. Racing thoughts. 6. Decreased need for sleep. Copyright 2011 THERAPYTOOLS.US All rights reserved