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From Diagnosis To Direction: Evidence-Based Help For Defiant Behavior · Inside The Consulting Room - Understanding the Child Behind the Behaviour

• 0:00
  SPEAKER_00: Hello and welcome back.
• 0:01
  SPEAKER_00: This is Kim Lee, child and adolescent psychotherapist from the Children's Consultancy, and this is episode three in the series to do with oppositional defiance disorder.
• 0:15
  SPEAKER_00: So, what I want to try and do here is to take a look at the ways in which, with an understanding and also with an accurate diagnosis, we can take a look at what treatment options or modalities are most actually helpful.
• 0:39
  SPEAKER_00: So the first thing to say is that this is a condition which is highly treatable.
• 0:46
  SPEAKER_00: A lot of people receive a diagnosis, look for a diagnosis, and might think once we have that, then that will help.
• 0:58
  SPEAKER_00: Well, a diagnosis is only as useful as what follows on.
• 1:03
  SPEAKER_00: So a diagnosis is something which you receive at the end of an appropriate and qualified assessment.
• 1:12
  SPEAKER_00: That then makes it possible, certainly, for us as clinicians, to help parents to look at what what it is, what are the things they can do which are most likely to assist growth, development, and recovery.
• 1:29
  SPEAKER_00: This is important because every child I see is on a particular kind of trajectory, regardless of the difficulties they're experiencing.
• 1:40
  SPEAKER_00: I am aware of where the difficulties are likely to go if untreated.
• 1:46
  SPEAKER_00: But before I can make recommendations about treatment and look at approaches, I have to have a clear understanding of what it is that needs attention, how that became the case, where that will likely go, in the sense that if it's left to its own devices, so to speak, what will happen next two years' time, three years' time, and so on.
• 2:09
  SPEAKER_00: So this enables us to intervene meaningfully and most importantly, alter that trajectory.
• 2:26
  SPEAKER_00: Many parents, out of frustration and out of desperation, might punish the child.
• 2:34
  SPEAKER_00: And it won't work because if it did, you wouldn't have to keep doing it.
• 2:40
  SPEAKER_00: So we have to think about what is more likely to work.
• 2:44
  SPEAKER_00: Now, treatment approaches are underpinned by the notion of regulation, that means managing emotional states, relationship, and that is the context in which the damage may very well have occurred, and how we use the relationship as a reparative structure.
• 3:08
  SPEAKER_00: And we have to look at the environment.
• 3:12
  SPEAKER_00: And by environment, I mean the emotional environment within the family structure.
• 3:20
  SPEAKER_00: Now there are a number of evidence-based treatment modalities, and the first I'd like to talk about is parent management training, which teaches parents to use consistent realistic boundaries, reinforce those behaviors which work, and we need to name that something has worked, how and why it has worked.
• 3:46
  SPEAKER_00: We need to learn how to avoid cycles of escalation and learn de-escalation techniques so that we can reduce the power struggles that normally end badly and increase the emotional containment both as parents and in the child.
• 4:05
  SPEAKER_00: Another, I mean, this is generally regarded as one of the most effective treatments.
• 4:10
  SPEAKER_00: Why?
• 4:10
  SPEAKER_00: Because it has its roots in psychoeducational thinking.
• 4:15
  SPEAKER_00: But it's really about teaching parents how to do this, which is something I spend a good deal of my time doing.
• 4:22
  SPEAKER_00: Another approach that is considered as potentially helpful is cognitive behavioural therapy, which I'm sure many of you will heard of.
• 4:31
  SPEAKER_00: And the claim here is that this will help the child to identify triggers, develop emotional regulation, and reduce impulsivity, improve frustration tolerance, and challenge the hostile thinking patterns.
• 4:49
  SPEAKER_00: Now, whilst that is the claim, I'm more inclined to think that an approach of that kind, which pays attention to the behaviour, dramatically misses the underpinning mechanisms which are responsible for the behaviours.
• 5:10
  SPEAKER_00: It also doesn't take into account the family context and a whole series of other relational factors.
• 5:19
  SPEAKER_00: The other thing to say about CBT is that it is very rare in my experience for children and often young people to benefit.
• 5:28
  SPEAKER_00: And that is because the requirement post-session involves homework, and that generally speaking won't happen.
• 5:40
  SPEAKER_00: If it works, fine.
• 5:46
  SPEAKER_00: But every child is different.
• 5:48
  SPEAKER_00: There's a model that was put forward by somebody called Ross Green, and it's called the Collaborative and Proactive Solutions Approach.
• 5:58
  SPEAKER_00: And that focuses on the understanding of the lagging skills, those skills that are behind, again reducing power struggles, using a collaborative problem-solving approach.
• 6:13
  SPEAKER_00: I would use different terminology, but essentially it's about how we work retrospectively with the child, how we make sense of what's happened so that the child can learn with the parent how to spot the things which are trigger points, how we can increase the capacity for thinking over impulse, and how we can predict outcomes without the child crashing into an outcome and a consequence.
• 6:51
  SPEAKER_00: This is a particularly, I I think it's an intelligent approach.
• 6:57
  SPEAKER_00: My own experience of working in this kind of way, but using my own model, is that whilst it is it takes time, progress is significant.
• 7:09
  SPEAKER_00: Many parents will say, Well, we're still having episodes, but they are shorter and they're further apart.
• 7:17
  SPEAKER_00: And what I see is that something is shifting in the child.
• 7:21
  SPEAKER_00: There are no quick fixes.
• 7:23
  SPEAKER_00: These things do take time.
• 7:26
  SPEAKER_00: Another approach is that of family therapy, which I think is whether that comes in the form of understanding relational patterns, which are something I do a lot in parental guidance, or whether it's about looking at the family as a system, which then starts to see the broader context in which the patterns of difficulty are placed in.
• 7:54
  SPEAKER_00: So we look at things like parent-child power dynamics, emotional communication, attachment repair, but we're paying attention to the family as a system, not as a problem, or the child as a problem.
• 8:11
  SPEAKER_00: This is a highly specialized approach and normally lies with those people who have significant training in what's called the systemic family therapy approach.
• 8:25
  SPEAKER_00: Then, of course, there is the option of medication.
• 8:29
  SPEAKER_00: Now there isn't a direct medication approach for ODD, but some medications will inevitably be prescribed for ADHD, mood dysregulation, and severe impulsivity from which the ODD might emanate.
• 8:50
  SPEAKER_00: So when I talk about co-occurring, if the ODD, which is rarely a standalone condition, is attached to these other things, then there is going to be a benefit.
• 9:02
  SPEAKER_00: The other thing I would say is that trying to work with children psychoeducationally if they are unmedicated, is a bit like trying to plant trees when there are forest fires.
• 9:14
  SPEAKER_00: So there's something to be said for looking at how we intervene in a way that reduces symptoms so that we can do the work.
• 9:23
  SPEAKER_00: And this is this is very important.
• 9:26
  SPEAKER_00: It's a much more intelligent approach.
• 9:28
  SPEAKER_00: Medication on its own will, yes, it will moderate symptoms, but once again we're back into the territory of treating behavior without paying attention to causation.
• 9:40
  SPEAKER_00: But I think the most important thing, the most powerful treatment factor is the relationship between child and caregiver.
• 9:49
  SPEAKER_00: And then when that connection improves, then the need for defiance reduces.
• 9:55
  SPEAKER_00: Parents get pulled in and locked into self-maintaining patterns, not a criticism, an inevitable reality.
• 10:06
  SPEAKER_00: As a clinician, one of the things I frequently do is to pay attention to those patterns in a way that says, look, let's see where everybody's stuck.
• 10:17
  SPEAKER_00: Then that makes it possible to look at different approaches.
• 10:21
  SPEAKER_00: And in my experience, almost every parent is receptive to that.
• 10:27
  SPEAKER_00: In the next episode, we'll look at what are called differential diagnoses.
• 10:31
  SPEAKER_00: And in simple language, that means let's be clear about what this is and what it isn't, so that we don't get locked into a particular view which misses the larger picture.
• 10:44
  SPEAKER_00: And that, of course, is a particularly specialized clinical task.
• 10:48
  SPEAKER_00: But for now, I do hope this is helpful.
• 10:52
  SPEAKER_00: We have two more episodes, and we're also going to take a look at conduct disorder and the difference between that and ODD, although sometimes they look similar, and a few other things which will help us to be clearer about what these symptomatic behaviors are telling us and are not telling us.
• 11:18
  SPEAKER_00: And thank you for listening.
• 11:20
  SPEAKER_00: Hope this has been helpful.