Literature Review and Analysis - Oppositional Defiant Disorder in Adolescents

A. Client Identification

Kayla is a 14-year-old, Caucasian, female that identifies as pansexual. Kayla has struggled with her depression and anxiety for the past three years. She recently had a suicide attempt where she ingested more of her medication than prescribed, guanfacine, while her parents where not home.

B. Presenting Problem(s)/Symptom History

Kayla reports that she started feeling really depressed a few years ago but that she can’t identify any causes, “it just started happening.” She also began using cutting as a coping skill about two years ago. She reports thinking about suicide daily and cutting at least twice a week. Her mother identified the problem first because she also cut as a teenager. She had her first suicide attempt at the age of 12, she tried to ingest chemical cleaner but didn’t consume very much as she says the taste was too unpleasant. She was hospitalized for ten days at a psychiatric hospital and then completed two weeks of intensive outpatient treatment. This treatment was also accompanied with 15mg of Lexapro for depression and 5mg of Tegretol as a mood stabilizer. Kayla reports that she was stable during treatment but when it ended Kayla declined and started feeling depressed and cutting again. Kayla’s mother believes this was due to the lack of structure in their home. Last year they switched Kayla from Tegretol to 1mg of Intuniv because Kayla became aggressive on the Tegretol and had some outbursts that included a physical altercation with her mother. Kayla reports that she thinks about suicide often, but it isn’t always an “active” thought. She reports that her depression is pretty much every day for most of the day, feeling sad and hopeless. Kayla says that she has lost interest in skateboarding and crafting which she used to love. She has also started isolating herself. She believes she suffers from this because it runs in her family. Her recent suicide attempt was in January where she ingested more than her prescribed dosing of her prescribed medication, she is unsure of how many she took. She was given activated charcoal and slept for over 36 hours straight. She had an upset stomach and two nose bleeds the following day. Her mother declined hospitalization, but the family developed a safety plan and made attempts to strengthen the support system at home. Her mother also switched her to a new psychiatrist and Kayla currently takes 100 mg of Zoloft, 100 mg of Trazadone, and 2mg of Intuniv. The most recent concern is that Kayla’s behavior has started expanding to her school environment. She has skipped one class where she asked to go to the bathroom and didn’t return for forty minutes. Kayla also has been disruptive and argumentative in three other classes that resulted in disciplinary actions. Two teachers have called Kayla’s mother to discuss the incidents. Kayla was argumentative with the teachers, causing a scene during class that included standing up, walking out, and crawling around the floor “pretending to be a rat”. Kayla’s adoptive father reports that she is equally defiant and aggressive when she visits his house as well, especially when it comes to contributing to household chores or tasks. Kayla’s episodes occur daily.

C. Individual History

Kayla is 14-year-old Caucasian female. Her family is between a lower and middle socioeconomic status. She is a full-time student in the 8th grade at a public school near her home Kayla was born to Samantha and John in a rural area in Texas. Kayla reports that her mother has mentioned how abusive John was during the pregnancy and when Kayla was six months old Samantha moved in with Allen to “get away” from John. Allen had two daughters, that are older than Kayla. Samantha and Allen had a baby when Kayla was one and then got married when Kayla was two. Kayla lived with her biological father for a few months when she was seven but quickly moved home due to abuse. When she returned to Texas, her biological father’s rights were terminated, and she was adopted by Allen. Samantha also adopted Allen’s two daughters from his first marriage at the same time. When Kayla was nine her mother became involved in a polyamorous relationship involving another woman. Kayla’s biological mother and adoptive father were divorced when she was 12 and the extramarital relationship was also dissolved that year. Kayla has a good relationship with her mom and her mom’s fiancé, David. She visits her adoptive father, Allen, every other weekend where she stays with him and his fiancé and her two kids, a boy and a girl, who are older than Kayla. Client reports that she and her three sisters all share one room at her dad’s house, so she doesn’t like to stay for long periods of time. Kayla reports that she has a few friends in middle school but tends to isolate in her room. Kayla identifies as Pansexual, but her sexual attraction tends to lean more towards females right now. She is not currently sexually active. She has also mentioned that her dad says he is okay with her sexual orientation but tends to speak negatively about it to her and asks her not to talk about it outside of their immediate family. Kayla reports that she has smoked a cigarette before and that she has recently tried smoking marijuana once. She has tried drinking alcohol but says she does not like the taste. Kayla has no medical diagnosis but is currently overweight. Kayla has attended public school regularly since Kindergarten. She was also admitted into the Pre-K program after her family met the low-income requirements. Kayla says that she is bullied often because of her weight and her sexual orientation. She has made a few friends in middle school, and identifies one friend Allie, to be a great support to her. Kayla makes good grades and is in advanced classes. Kayla has an ex-girlfriend that has been “playing mind games” and bullying her at school. Kayla has been in therapy since she was 11. She has seen the same therapist the whole time. She is reporting that she doesn’t trust her anymore because Kayla feels that the therapist is always suggesting hospitalization to her parents. She admits that she has learned a few things from it but doesn’t want to see that therapist anymore.

D. Family Information

Kayla’s mother, Samantha, was diagnosed with depression during her pregnancy with Kayla and began taking Lexapro. Samantha was diagnosed with bi-polar disorder when Kayla was 9 years old and has since seen a therapist regularly and a psychiatrist for medication to be stable. There is no reports of suicide attempts in any of Kayla’s immediate family, but Samantha reported that her mother attempted suicide about 5 years ago with medication overdose as well. Kayla’s maternal grandmother is also diagnosed with bi-polar disorder. There are no reports of substance use or abuse in Kayla’s immediate family, but her maternal grandmother is an alcoholic. Child Protective Services has made two visits to the family, both times were reported by the school. One incident involved recurring head lice and the other was for a bruise on Kayla’s face. The bruise was caused by an accident on a trampoline where Kayla says her cheek hit her little sisters head when they were bouncing too closely. Both reports were dismissed. Kayla says that she feels she has a strong support system. She openly talks to her mom and David frequently and has a strong relationship with her mother’s best friend Alice, who she considers her Aunt. There has been some discussion of Samantha being verbally aggressive towards Kayla when Kayla was younger, Samantha reports that they were before her diagnosis and before medication stabilized her moods and limited her experience of episodes. Kayla is also very close to her older sister Michelle even though they are not biologically related. The whole family seems to have strong connections to each other and are very supportive which is a strength of theirs. The family also seems to have a good developing support system consisting of close friends and Kayla’s mother’s fiancé’s family. They all seem to want to help and do what they can to encourage Kayla and her treatment.

E. Social and Cultural Environment and History

Kayla believes that she “got this” from her mother because her mother has a mental illness and so does her maternal grandmother. She says she feels like God is punishing her and often asks “why me?” The family doesn’t report to have any religious affiliations, but Kayla’s mother says she teaches them to be spiritual and believe in God. Kayla’s adoptive father reports that he doesn’t understand why Kayla acts like this and that he believes it is “all in her head and she is just going through a phase.” Kayla’s mother has always encouraged them to reach out for services and that they live in a suburban area where access to services is available. Kayla is aware that she has poor coping skills and needs better ones. She also reports that she wants to just “feel better”. Kayla reports that the trigger for her latest suicide attempt was the ex-girlfriend at school and has since cut connections with her. Kayla also mentions that the ex-girlfriend moved away last week. Kayla’s mentions that her current person of interest is an African American girl of the same age.

F. Mental Status Exam

Kayla’s appearance has remained mostly consistent. She wears coordinating clothing, sometimes with stains, they are loose fitting and often repetitive outfits. She often has a slight body odor smell and oily looking hair, her mother reports that she has had to force her to shower at times and consistently have to remind Kayla to use deodorant. There are times that Kayla has gotten up in the middle of the night to shower, which happens about once a week. Kayla is very lethargic and seems very sleepy if her appointment is before 2 PM. Kayla reports that she doesn’t get a lot of a sleep and although she takes Trazadone to help for sleep, she feels it isn’t working. She slouches in the chair and appears very uninterested and distracted. She is overweight and admits to getting up to eat in the middle of the night because she feels hungry. Samantha says that Kayla has gained quite a bit in the last year and Kayla’s pediatrician has expressed his concern about her weight gain at her last annual checkup. Her fingernails are very short from biting them and she has sores around her cuticles. Kayla will make eye contact when asked a direct question but only after getting her attention. Her interactions have been aged appropriate including her use of vocabulary and speech level. Her tone has been melancholy, low and soft. Kayla’s affect seems to be depressed, easily annoyed and often gets angry very quickly. Her thought process seems to be appropriate however there is evidence of flight of ideas. She is oriented and intelligent. There is no evidence of cognitive limitations or learning difficulties. She has reported issues with her short-term memory and getting distracted easily. When Kayla is asked about her behavior outbursts, she responds that she feels her parents and teachers expect too much and often make unreasonable demands.

G. The DSM-5 Diagnosis

Diagnosis: Oppositional Defiant Disorder – Severe

Kayla exhibits a pattern of angry/irritable mood and argumentative behavior for more than 6 months and has the following five symptoms: often loses temper, easily annoyed, often angry, often argues with authority figures, actively defies or refuses to comply with requests from authority figures. These disturbances in behavior are having negative impacts on her educational and social areas of functioning. They are not exclusively during depression. She is considered severe because the symptoms are present in three or more settings. It is not diagnosed conduct disorder as there has been no reports of aggression toward animals, destruction of property or a pattern of theft or deceit. Also, because of the emotional dysregulation it is not included in conduct disorder.

Diagnosis- Major Depressive Disorder

Kayla reports that she is depressed nearly every day for most of the day. She also has expressed a diminished interest and pleasure in activities and has started isolating. She had a significant weight gain and reports having insomnia most days. She also suffers from fatigue or loss of energy nearly every day. Kayla also reports that there are recurrent thoughts of death, recurring suicidal ideation with attempts. She does not have any medical conditions that could contribute to the mood disorder. Her symptoms cause significant distress and impairment in her social, educational, and other important areas of functioning. Kayla is also approaching the two-year mark for symptoms and could possibly change the diagnosis to Persistent Depressive Disorder/Dysthymia.

Part 2 – Screening for Treatment or Referral

According to the responses to the above, the client is going to remain under our clinical care. Our clinical setting, we are a private practice that does psychotherapy. With Kayla, the treatment priorities are going to be coping skills to minimize self-harm and suicidal ideation, CBT (cognitive behavioral therapy) to help create a new way of thinking about or acting on problems that arise and working on social skills training. We are also going to take a focus on building self-esteem. We are also encouraging Kayla’s parents to attend the Parenting Management Training classes for eight weeks to build tools in hands on parenting with children with ODD. We also offer a skills support group once a week for adolescent girls her age and would like her to attend them. Kayla will also continue seeing a psychiatrist and working towards a medication combination to help stabilize her.

Part 3 - Review of the Existing Evidence from the Literature - Literature Review (2 pages with 4 references minimum)

References

Ghosh, A., Ray, A., & Basu, A. (2017, November 29). Oppositional defiant disorder: current insight. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5716335/

Mullen, S. (2018, November 1). Major depressive disorder in children and adolescents. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213890/

Rice, F., Eyre, O., Riglin, L., & Potter, R. (2017, January 10). Adolescent Depression and the Treatment Gap. Retrieved from https://www.thelancet.com/action/showPdf?pii=S2215-0366(17)30004-4

Steingard, R. J. (n.d.). Mood Disorders and Teenage Girls. Retrieved from https://childmind.org/article/mood-disorders-and-teenage-girls/

Sukhodolsky, D. G., Smith, S. D., McCauley, S. A., Ibrahim, K., & Piasecka, J. B. (2016, February). Behavioral Interventions for Anger, Irritability, and Aggression in Children and Adolescents. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4808268/

Part 4 –Review of Salient Data from the Case and the Literature (1-2 pages)

Part 5 – Prioritizing Treatment Outcome Goals and Setting a Treatment Plan

· Treatment will consist of Individual Psychotherapy twice a week for six weeks, and then once a week for six weeks to achieve the following goals:

· Goal 1 - Reduction of suicidal ideation to no more than twice a week and reducing the self-harming to nonexistent.

· Treatment Plan

· Assessment

· Using of C-SSRS (Columbia-Suicide Severity Rating Scale) at each visit.

· That will gauge the severity of level of ideation on a scale of 2 to 25, with a higher number indicating more intense ideation and greater risk and track changes in levels.

· Developing healthy coping skills

· Cognitive Behavior Therapy

· CBT will be used to manage anger, control emotions and develop problem solving skills to replace defiant behaviors.

· Mood Journaling

· To help the client build self-awareness about connecting events to mood and thoughts and then connecting that to behaviors.

· Determining how it was achieved

· The clients score on the C-SSRS will decrease during treatment, her suicidal ideation will decrease from daily to no more than twice a week, and client’s cutting behaviors will be eliminated.

· Goal 2 - Improve family relationships between the parents and the client where the outbursts/episodes are occurring no more than three times a week.

· Treatment Plan

· PMT - Parenting Management Training Program - Class meets once a week for 8 weeks.

· Educating parents how to respond during stressful and exhausting times to avoid setting negative antecedents that could encourage bad behavior.

· Equips parents with tools to change current bad behaviors, develop and reinforce good behaviors, and create routines.

· PCIT - Parent - Child Interaction Therapy - 10 sessions starting after the completion of week four of the PMT course.

· Helps parents become better at managing defiant behaviors in real-time coaching by allowing the therapist to advise parents behind a one-way mirror or using “bug-in-the-ear” method, so the child connects the parenting skills to the parent and not the therapist.

· Helps parents to develop, reinforce, and utilize what they learned in the PMT course with guidance to build consistency.

· Collaborative Problem Solving Skills

· Helping the parent and adolescent develop a mutual understanding of the problems and concerns.

· Developing a collaborative environment that focuses on solving the problems in a way that are mutually beneficial rather than using a reward-punishment system.

· Determining how it was achieved

· Parents will have completed at least 4 weeks of the PMT course and at least two sessions of PCIT.

· Conflicts between parent and children will be resolved without escalating to an outburst/episode from the client. Outbursts/episodes will decrease from daily to no more than three times a week.

· Goal 3 - Development of social skills that will decrease outbursts at school, resulting in no disciplinary actions for at least a month.

· Treatment Plan

· Group Therapy - Social Skills Development Group

· The client will attend weekly group therapy sessions in our Social Skills Development Group for adolescent girls ages 13 - 17 on Saturdays.

· 504 Program Assistance

· Assist client’s parents in preparing and establishing a 504 program at the client’s school by collaborating in an interdisciplinary team with the school and client’s psychiatrist.

· Determining how it was achieved

· The client received no disciplinary actions while at school for a period of one month.

· Establishment and utilization of a 504 program.

Part 6 – Treatment Evaluation

The client will be evaluated at the six-week mark to see if there has been improvement. We will reassess using the C-SSRS for current level of suicidal ideation and self-harming behaviors. We will use self-reporting from the client and reporting from parents to evaluate current mood stabilization and occurrence of outbursts and episodes at home and at school. Will use self-reporting from the parents and reporting from the client in regards to the usefulness of the PMT course and the PCIT sessions. Obtain current observations of the client in the school environment from school staff to assist in evaluation of the social skills development and the implementation of the 504 programs. Utilize the Behavior Rating Inventory of Executive Function (BRIEF) parent assessment scale and the Emotional Intelligence (EI) assessment for the child to evaluate level self-awareness in the client. Compare the results given to specific goal measures to decide if a treatment plan needs modifications or additions and judgement on treatment efficacy. Continue to evaluate progress and make modifications as necessary to better serve the client and their family while improving their quality of life.

Figure 1: Genogram

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