Now there’s a complete shocker. Would you please elaborate as to what sort of parental training and participation are required in order to effect proper treatment?
Please mention which drugs are being evaluated at this time.
I think that last bit needs a bit of expansion.
If I want my kid’s psych visit to be covered he needs an ICD-9 code. Getting counseling for his anxiety or meds for his focus and impulse control (or what have you) will be paid for if he has an illness label, it won’t be if he doesn’t have one. The school will provide extra services to help develop his err “emerging” organizational skills if he has a label and won’t if he doesn’t. The pressure to pathologize is huge.
** Ah. In that case, I think I owe you an apology: that statement isn’t actually very clear, now that I read it again.
The point I was trying to make at the time was that those side-effects occur in children regardless of whether they are diagnosed with ADHD or not, hence the “all children”; I didn’t actually mean that each and every child experiences those effects when taking stimulants.
My sincerest apologies. Your criticisms of this statement are quite correct.
** Actually, it’s more often the other way around. Endogenous and exogenous depression are no longer considered meaningful categories because of research that showed that the labels made no difference to therapy responsiveness or treatment utility.
The problem is that entire diagnostic categories come into being, are preserved, and removed, without any scientific arguments being made. Self-defeating personality disorder wasn’t disproven, it was merely politically incorrect. The criteria for depression or schizophrenia or ODD are not attempts to describe known physiological problems, but are only symptomatic descriptions that exist on a continuum with normality.
** Psychological research refers heavily on the DSM categories – that’s how research subjects are identified. At the same time, such research generally has to come up with its own operationalizations of these conditions precisely because the DSM is so vague.
This one short, double-edged statement summarizes so much of what made me start this thread in the first place. It almost deserves a thread of its own.
TVAA,
Apology accepted.
And the non-difference in treatment or likely similar/same underlieing pathohysiology between endog and exog depression leading to just one label is again the point: these are labels used to guide further research, to test the hypotheses, and to change as data becomes available and interpreted. Yes, research refers to models available as it tests them. Yes research uses the dictionary availble and specifies as needed. And then modifies or replaces models to fit the data so obtained if needed. That is how science works.
Zenster,
Feel free to begin one. I would guess that you’d find lots of this same crowd agreeing that history and society has placed us a situation where such is true. Almost every therapist has to have spent time wondering what label to attach to a particular client for coding purposes … not to guide clinical care, but so the client can get insurance to cover it. Truthful labels perhaps …
The problem is that the basic assumptions themselves are often not evaluated. For example, we have no reason to believe that people who generally fit the description of being depressed but for a shorter period of time are actually different in any important way than those who aren’t.
There’s also the tremendous problem that the categorical definitions themselves are extremely broad.
But your example illustrates something otherwise: chronic and acute depression are fundamentally different in at least one important way: natural history. If it is true that the pathophysiology is otherwise nearly exactly the same, then it is even more interesting and important to understand what small differences exist that make some depressions short-lived and others chronic.
“… extremely broad.” Well we’ve covered the fuzziness issue already. Are you now suggesting that clinical care and/or research would be better served by further splintering of current labels? My take on that is that such is warranted once you show that some clustering of features has a significantly different natural history or response to treatment than another clustering of features currently within the same label. I understand your concern that the labelling may in and of itself get in the way of uncovering these differences but the evolving nature of the DSM and of active research convinces me that such is not a justified concern.
I don’t understand the sarcastic attitude, unless I am misperceiving you, in which case I apologize. In general, parenting components of therapy include basic education in child behavioral managment, and specific training in constructing a behavioral program that balances reinforcement with punishment. Training may include giving effective commands, reinforcing desired behavior, being consistent, using time out procedures correctly, choosing battles, increasing non-directive play activities with the child, and not engaging in parenting behaviors that tend to elicit or escalate unwanted behavior. With adolescents, additional components include negotiation strategies, listening skills and communication skills. Parent Child Interaction Training involves observing interactions between a parent and child through a one-way mirror, and communicating to the parent through a bug in the ear about what to do and say with the child.
Parent participation in parent management training is obviously crucial.
The literature on medication evaluations for ODD and CD suffers from the same problem that much of the literature on these disorders does - there is a paucity of research suitable to disentangle these disorders from one another, as they are too often lumped together to be studied as “behavior disorder” or “behavior problems” or may simply focus on aggression. Burke et al., 2002, identified very few randomized controlled trials (RCTs) for these disorders, and concluded that “Until further studies are carried out, the clinican may consider using these medications for the managmenet of youth with severe or non-responding CD.” Of the literature available, two RCTs found lithium to be efficacious and safe for treatment of aggressive CD. Another compared lithium, haloperidol and placebo, finding that the two were more effective than placebo, while haloperidol was less well tolerated than lithium. Another study found that carbamazepine was not significantly better than placebo in treating aggression. Molindone and thioridazine were included in one RCT, and were found to be effective. Risperidone was found to be superior to placebo in another. Methylphenidate was identified as effective for treatment of CD in another. Two small studies of clonidine found it to be effective.
On the whole, insufficient study of pharmacotherapy for ODD and CD has been conducted.
Much of the discussion in this thread is irrelevant to ODD. For example, the issue of whether ODD is dependent on a definition of legitimate authority is almost entirely a red herring. These are not children engaging in civil disobedience, being persecuted for wearing a “Free Mumia” t-shirt to school. In fact, defiance is relevant only for one symptom (defiance and non-compliance), and indirectly for arguing with adults. Often losing one’s temper, deliberately annoying others, blaming others for one’s behavior, being easily annoyed, angry and resentful and spiteful and vindictive are less Gandhi like aspects of ODD.
Additionally, if one wishes to dispute whether a parent can compel a child to participate in therapy, one may also dispute whether they can compel them to do their homework, come in at curfew, or go to grandma’s house for Sunday dinner. Parents are the legitimate authority of the child. Children with this disorder are at risk for a range of negative outcomes, and are not fighting against abusive conditions for some higher moral purpose. It is a perfectly legitimate parental response to try to prevent truly negative outcomes, such as school failures, progression to CD and risk for involvement in criminal activities.
It is all well and good to say that abuses occur in psychological and psychiatric treatment. It is only useful when any sort of information is presented about how often, in what circumstances, and under what conditions these abuses are occuring. I would be particularly interested to see any information to suggest how these problems are specifically relevant to ODD. That is, what data or evidence is there that abuse on the part of treatment providers is occuring regarding ODD?
My vita: I have a PhD. I am a licensed clinical psychologist. I have published 10 papers in the area of disruptive behavior disorders in children (9 peer reviewed and one book chapter). I maintain a small clinical practice, primarily with children, much of which involves evaluations for wraparound services for more severely impaired children.
Relevant to this discussion, I have a paper currently under review which examines the relationship between conduct disorder and depression. A novel finding was a direct link from ODD to subsequent depression.
No, you’re not understanding what I mean by “extremely broad”. The criteria themselves are fuzzy, requiring a great deal of interpretation. For example, just what is “excessive” defiance? There’s no way to generate a quantitative standard from that criteria.
Hentor
would you see many cases of ODD where the disorder is a direct result of the parenting?
Many? No. There are certainly times when I think poor parenting reflects the lion’s share of the problem by the time I see the child, but even then it is not possible to be certain about the degree to which noxious child behavior may have elicited poor parenting. It does take two to tango. Parenting training is a crucial part of treatment because, regardless of the origin of the problematic behavior and the quality of parenting already present, the results of that behavior are key to whether it will persist or diminish, and parents are key in terms of shaping those results. Even good parents are not necessarily inherently well equipped to respond to very difficult child behaviors.
Thanks Hentor. That was what I was hoping you would say – there’s a distinct flavour from some posters that bad parenting is a major part of ODD and I think it’s a significant point that it’s very hard to tease how what came first. Difficult child, crap parenting or vice versa.
Thank you for the well thought out posts, Hentor. I’d also be interested in your take on the value (and current tendency) of pathologizing every muscle tic that comes down the pike. I’ve noted in an earlier post that pathologizing is a dual edged sword. While it provides a route to identify and validly treat disorders, it also can increase the stigma of what may often be symptoms in the absence of complete expression.
I guess I would want to understand better what you are talking about, Zenster, to better answer your question. Who is doing this pathologizing of every muscle tic? What is the nature of the current tendency to do this? What evidence do you have that we can use to refer to as a basis for this discussion? How does it relate to ODD?
I know that I see occasions where previous clinicians have given diagnoses that made me wonder what they were looking at? I know that this occurs less frequently than I see diagnoses that I feel are spot on. There are times where parents, for whatever reason, are looking for me to give a more severe diagnosis that just isn’t warranted. There are also instances that parents have brought up an eye catching but isolated behavior that I gasp have told them isn’t something to be unduly concerned about.
So, I think it would be helpful to be more specific about the phenomenon under discussion.
I’m sorry I came to this thread so late, but since my current assignment bans message boards, I don’t frequent SDMB much anymore. Having said that, I have only scanned the posts, and will read them in more detail on the train in the morning. If I have something else to add, I will do so.
I am the father (non-custodial) of a (formerly, but still borderline) ODD child. My first reaction was that I don’t simply want a label as an excuse (just the opposite of his mother). I had a very long talk with the abnormal child behavior psychiatrists as to what constitutes the difference between an unruly, hard-to-control, but still normal child and one with ODD. With that, coupled with another problem my son is still facing (the original reason we were seeing an abnormal child behavior psychiatrist), I was convinced that he was indeed facing a problem that wasn’t just pure pigheadedness.
My son is responsible for his behavior. ODD isn’t an excuse for him to behave poorly. What it does, however, is remind me that, despite using every tool in the normal child behavior handbook, there is a reason he is not responding, and that when stressed he shows the maturity level of someone half his age. He can’t control it, and when he calms down he realizes what went wrong, and he works to control his impulses. Thanks to therapy, plus increased patience due to the understanding that his parents weren’t doing anything ‘wrong’, we’ve all but eliminated the most extreme flare-ups.
Do I think people are diagnosed with a condition as a panacea. Yes. But just as I won’t let a medical doctor prescribe antibiotics for a simple cold or virus, I wouldn’t let the psychiartrist bucket my child - that is not unless I was fully and firmly convinced it was true.
If you are a parent, trust me - you don’t ever want to deal with an ODD child.
P.S.
We were able to treat our son without medication, something I was VERY strongly against, and that I made clear was a ultimate last resort option.
P.P.S.
Jeez, this tread is huge - 86 printed pages. Unfortunately, I will have time to attack this tomorrow.
** And this entire scenario doesn’t strike you as a problem?
When physicians rely on what they feel about therapies, they’re frequently wrong. There have been treatments that doctors have been personally convinced are effective and necessary that independent empirical testing has shown to not only be useless but actively harmful.
Your implicit beliefs about the correctness of diagnoses should not come into question, and yet they’re the standard by which you’re judging the diagnoses of others (at least, so you imply).
I’d love to agree with you, can you show where you learned all this stuff about how they’re frequently wrong when they do this?
Once again, I defy you to provide some evidence that you’re not just making stuff up.
Never said it wasn’t.
This sentence is hard to decipher. However, I take it that you are asserting that I said the correctness of diagnoses should not come in to question. Again, I never said this. I never said diagnoses were perfect. I never said the diagnostic classification system was perfect. Quit spewing fabrications and nonsense. Please present some evidence for any of your views. Please present any support for your assertions as to what I have said. Otherwise, I will simply add this to the steaming pile of unsupported ranting you offer.
TVAA, to Greck
[QUOTE]
Don’t you know anything about the way our medical systems work? Children and adolescents do not possess the right to refuse medical treatment of any kind. Their legal guardians (usually their parents) have that right.
Yes, this is an aspect of the legal status of being a child. If you are a child, your parents can enroll you in a boarding school, and that becomes the place you legally belong even if you don’t like the teachers. If such a school were to install physical barriers to prevent the children from running off, they would be well within their rights as long as they don’t create fire hazards or something.
So naturally they can place their children in a medical facility and, again, the children do not have the right to leave.
In the specific case of psychiatric facilities, clinical personnel have some authority to prevent parents from removing a child placed in their care if they believe the child to be in need of continued treatment. I’m in the process of digging up some references on that. Specific OMH statutes will vary from state to state.
Greck, to TVAA earlier:
In addition to not having the right to leave, a child does not have the authority to consent to medical treatment. Authorization is provided by the parent or guardian as a matter of policy and law. In practice, with regards to psychiatric treatment, such authorization is usually provided by the parent to the facility in a broad general format that permits the facility’s clinical personnel to make the fine choices such as whether or not to administer involuntary psychotropic medication.
Again, I am in the process of compiling some citations for you, and, again, specific OMH statutes vary from location to location. I should add that actual practice may differ from policy, and that in most locations it is not mandatory that facilities report the rates of treatment and whether or not each instance of treatment was voluntary or not. Here in NY our lobbyists managed to get the state Senate and Assembly to pass a bill requiring this kind of reporting with regards to electroshock (ECT), for which we have more support and momentum than for the drugs, but Governor Pataki just vetoed it.
People need to retain the right to be obstinate and unamenable in the face of pressure to change in directions that they do not wish to change. That’s the whole point of having a say in one’s therapy.