Good evening everyone!!

It is yet again late Monday night and I have not written a medical blog post for the week (*face palm*).  Sorry!  In my defence, I’ve had a bit of a rough old week, with many sad anniversaries (5 in total) for me in the last 7-8 days.  It was very considerate of our late family members to all time their passings for the one week of the year (meaning we can just have one sad week rather than multiple), but it does make for a high grief tide around Easter time, and I must admit that I do struggle a bit.

So today I have been hard at work, not blogging but instead working on my uni Masters subject.  I managed to get through 2.5 weeks worth of material in one very solid day (8 hours, no lunch break) so I am pretty pleased with myself. Only 1 more discussion board contribution and an assignment to do for this semester, then one more subject next semester and I’m done. Never to return to Uni again (hopefully).

A few people have been throwing me out some topics to cover – some examples have been:

• Oppositional defiant disorder (ODD)
• Foetal alcohol spectrum disorder
• Poo smearing (sorry Teesh, I need to read up on this one… I really don’t know much about it)

I’ll start on the first tonight and get to the others soon.

 

The topic of Oppositional Defiant Disorder is a difficult one… and a really common problem that I encounter, in both public and private work.  ODD is a disorder of childhood development that causes a child to be easily angered, aggressive and disagreeable (won’t do what is asked of them) most of the time for at least 6 months.

It can be tricky to differentiate between an emotional or strong-willed child from one who meets the diagnostic criteria for Oppositional Defiant Disorder.  This is why it is really important that you see your local friendly paediatrician if you suspect your child may be having problems.  All children can be defiant and oppositional at times, and this can all be part of normal development – testing boundaries and establishing independence and autonomy.  Not all angry, disagreeable kids have ODD.  Anger, frustration and irritability are all very human emotions, and it is normal that everyone will feel these things at some time or other.  It is when these emotions and behaviours prevent the child from being able to function effectively in every day life for a prolonged period of time, that it becomes a concern.

The diagnosis of ODD is not one that I make often (in fact, I make it rarely at all).  It is not because the condition doesn’t exist – it does, but because I feel that the diagnosis isn’t very helpful for the child.  The diagnostic criteria as per the DSM-5 are set out below, but it is common that children with a diagnosis of ODD are labelled in the school and other environments as “the naughty child.” People’s opinions of that child from that point forward, can be clouded by the label, and then for the child it becomes a self-fulfilling prophecy… or what one of my colleagues (Dr Shellshear or “Uncle Ian”) calls “The Serious Reputation Disorder.”  In the public education system, having such a diagnosis does not qualify the child for extra assistance, even though children with ODD often have other difficulties such as anxiety, poor attention and/or hyperactivity and even learning problems.

 

What I DO find helpful, is trying to understand WHY the child is exhibiting the difficult behaviour.  I have written about this before in other articles.  When I see a child who presents with behavioural problems, I take a detailed history about pretty much every aspect of their life up until that point to try to figure out what is going wrong for them.  There are many factors in any one child’s life that affect their behaviour at any given time.  Things that cause stress or anxiety for the child can trigger difficult behaviour and can include (but are not limited to)

• Communication difficulties (eg a speech and language delay)
• Learning disorders and low academic performance; low cognition (problem solving skills) or memory difficulties
• Poor social skills
• Home factors – eg the relationship the child has with their parents, lack of secure attachment, inconsistent or overly harsh discipline, parental separation or other family stress, poor example set for the child in how to deal with stress in the past, new baby in the family, moving house
• Grief and loss
• Past exposure to trauma, violence, abuse
• Excessive digital/electronic device time; exposure to violent video games
• School factors – eg bullying, personality clashes with other students or staff, moving school
• Constitutional temperament – some kids are easy going and some kids are just not.

Often if we understand WHY the child is angry and irritable, it can be the key for us to find the right intervention to make things better.  Check out my past blog article on Angry Kids that talks about this.

It is also important to note that there are a few medical reasons why your child might be acting out, and these need to be properly investigated by your paediatrician. Some investigations might include a hearing test (we might be presuming that a child is refusing to follow directions, when in fact they just cannot hear them!), vision tests,  a sleep study (if there is suspicion of obstructive sleep apnoea), blood tests looking at iron levels, blood cell counts (to rule out anaemia), thyroid function and sometimes even investigations for epilepsy if there are markers for this in the history and examination… amongst other things.

 

So what criteria actually need to be met for a diagnosis of Oppositional Defiant Disorder to be given?

The child needs to display at least 4 symptoms from any of the following categories for at least 6 months.  If the child is less than 5 years of age, the symptoms have to be present on most days, if the child 5 years or older, then they must be present at least once a week and occur during interactions with at least one individual who is not one of their siblings.

Angry/Irritable Mood

1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.

Argumentative/Defiant Behaviour

4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.

Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months.

In addition to all of this, the child’s behaviour must be associated with distress in the person with whom they are interacting, or with others in their social context (eg school friends, teachers, family) or impact negatively on important areas of their everyday functioning (eg social interactions, education etc).  Other mental illnesses need to also be excluded including bipolar disorder, disruptive mood dysregulation disorder, substance abuse or psychotic illness.

 

So then if we have a child who is often angry, argumentative, disagreeable, obstructive, oppositional, defiant, nasty and/or unkind – what on earth do we do about it?

The answer is, “There is no one right answer to this question.”

Often the path of management will depend on the cause of the undesirable behaviour. So, for example, if a child is irritable, cranky and refusing to participate because he/she is having difficulties with communication (eg people just don’t understand them because of poor articulation or poor ability to express their intent), then the mainstay of therapy will be to see a Speech Pathologist for speech therapy.

If there is much turmoil or unrest at home, the way forward might be some family therapy with a psychologist to work on relationships and interactions at home.  It is always helpful for your therapists to be able to communicate their strategies with both yourself (the parent) and the school, so that a consistent and unified approach to managing the behaviours is used.

Invariably, a behaviour management plan will need to be devised for the child (and enacted by those caring for him/her) that:

• Tries to understand the cause of the behaviour, and to help the child understand how their behaviour affects other people
• Includes therapy aimed at teaching the child how to manage big emotions and self calming strategies
• Give the child tools to use to help when there are communication or problem solving difficulties

Check out this article that I wrote a little while ago with some handy tips on how to help kids (even really young ones) to build their resilience.

 

Some general strategies that can be used at home or in the classroom for any child who is experiencing problems with emotional regulation are listed below.  Note that no one approach will work for ALL children, and that we have to “be the adult” and stay one step ahead of the child.  The most important thing is to try to understand the cause of child’s behaviour, and then tailor the management strategies accordingly.

SCHOOL

1. Having structured and predictable classroom activities and schedule for the day. Visual aids (eg timetable charts) can be helpful reminders for children at transition times.
2. Giving children warning about upcoming changes in plans or activities
3. Supporting the child’s attention and concentration by setting the child up to minimise distraction (see my article on Strategies to support attention and concentration)
4. Rewarding and praising good behaviour often; pointing out the child’s strengths
5. Giving children a choice between a limited number (eg 2-3) options
6. Supporting the child’s learning needs

HOME

1. Reward charts
2. Giving simple, specific instructions and making sure what you are requesting of the child is reasonable given their developmental abilities
3. Give them warning of a change in activity, or an upcoming request beforehand
4. Noticing and praising good behaviour when it occurs
5. Have a calm discussion (when all is well and no one is in trouble) about what expectations of behaviour and conduct are in the house and what the consequences will be for not observing these
6. Be consistent with application of consequences when a child does not co-operate.

 

Challenging and undesirable behaviours in children have to be one of the most common problems that paediatricians deal with.  Often by the time the family come to see us, they are in crisis, the child has disengaged and everything is falling apart.  I have had some kids turn up to see me in clinic, after they’ve been excluded from every school in the district (I think the record stands at 9 schools) and their parents or guardians turn up ready to relinquish care.  This is an awful situation for everyone involved, the parents, the family, the school and not least of all for the child.  Keep in mind that the behaviours likely didn’t appear overnight, and so they likely will not disappear overnight.  Some children respond more readily to interventions that others, some are more tricky to manage.  In some children the cause of the behaviour is simple to fix, in others (eg in the case of exposure to serious trauma or abuse) the damage is extremely hard to reverse.  But don’t lose hope!  Your trusty paediatric health and allied health care professionals are trained to help you.

More often an evolving management plan over the longer term is what is needed, with consistency, collaboration and long term investment between ALL stakeholders – parents, teachers, therapists and doctors to work towards a positive outcome for the child.

I hope you have found this article helpful, and given that it is now 10pm, I am going to it the hay!  Another day of uni work awaits me tomorrow!  Don’t forget to leave me a comment, hit “share” or “like” to spread the word and to help as many parents out there as possible!

 

Until next time, stay well,

xxDr Megs