Q: I'm a public school counselor with a fifth-grade boy diagnosed with AD/HD and ODD. At least five behavioral plans have been tried unsuccessfully. What should I do?
A: Children diagnosed with oppositional defiant disorder (ODD) inspire many myths. School personnel and even parents believe that these children enjoy frustrating others, don't care what anybody thinks about them, and are impossible to teach.
But ODD is a label for various behaviors, and it indicates nothing about why such children act as they do. Are they experiencing repeated trauma? Do they have Asperger's Syndrome and are getting more sensory stimulation than they can handle? Are they worn out and angry from living with anxiety or depression?
Harried teachers and counselors often resort to interventions without devoting enough time to learning what's driving the child to behave in this way. Once a reasonable hypothesis has been made about the cause of their actions, however, cognitive-behavioral techniques and traditional relationship-building strategies can help even the most challenging children.
Tim, 11 years old and entering the fifth grade, angered not only his teacher and principal, but many of his peers. When I observed him in the classroom, he was distractible and impulsive, continually scanning the room, calling out, and touching things and people. There was no denying the glint in his eye when the teacher sent him off to the principal's office for the umpteenth time. He seemed to get satisfaction from the uproar he caused.
His history included a lengthy record of school failure, poor self-regulatory skills (problems during transitions, with little inclination to follow rules, listen to others, stop talking when asked, or keep his anger in check), and countless disciplinary events. The school and his parents had tried many behavioral interventions, but without success. These plans were based on traditional ideas about how to intervene, incorporating a cascade of rewards and punishments with little idea about what was driving Tim's behavior and without seeking his input. The plans were imposed on him, and he found ways to defeat them. He was embroiled in an ongoing, endless power struggle.
The staff was open to trying a different approach. I recommended that the full team—everyone involved with him, including his regular and special teachers, the school counselor, and the assistant principal—schedule a time to meet together. This meeting was to explore the context of his behavior, to find patterns in when he had difficulty, and to make sense of the times when he did well. If nothing else, I wanted the team to broaden its understanding and develop a hypothesis about the reasons behind his actions.
Meeting proactively, not in response to a specific incident, proved beneficial, as the staff displayed sensitivity and compassion. We addressed the sudden disappearance of his mother, his time spent in foster care, and his need to feel in control. I didn't use the label PTSD, but what we really talked about was the trauma in his life, a concept that allowed everyone to see Tim in a new light.
I pointed out that the earlier behavioral interventions had been forced on Tim without discussion about what they were supposed to achieve (besides making him somehow "behave better"), or even how they were supposed to work. This approach had left him clueless, struggling to retain a sense of control. Therefore, I suggested that before replicating this orientation to behavioral planning, his two main fifth-grade teachers and the school counselor discuss with him the purpose of the plan, how it would work, and the specifics of its goals and rewards. Because of their antagonism toward adults in authority, children with ODD seldom receive opportunities to contribute input to their own treatment plans. My request was that he be allowed the chance to do exactly this.
Children with chronically oppositional behavior typically are unaccustomed to articulating their needs, wants, and experiences in collaborative, problem-solving ways. I often speculate about possible goals and rewards in cases when the child appears to experience the collaborative process as too intrusive or anxiety-provoking. ("How about if we try to help you with this behavior?" "Would you be interested if we provided you with time on the computer when you earn a reward?")
Tim clearly wasn't used to a collaborative approach to planning his treatment, so instead of upping the ante with a confrontation, we calmly and pleasantly invited him to take full part in the process. We asked him how he thought his treatment and reward plan should be structured. He said he wanted the plan to be easy to understand, a private arrangement between his teachers and him, and one that enabled him to receive rewards more frequently than once per week; the proposal that he wait until Friday to get his rewards made no sense to him. He was the first one during the discussion to note that he needed to do better at "listening to his teachers."
I typically try to use this type of supportive, clarifying, nonjudgmental approach to help children participate in the dialogue. The point of proceeding in this way is to allow an oppositional child to experience a sense of personal responsibility, rather than depending solely on outside control and authority. Just including Tim as a collaborator in the planning about his treatment—maybe for the first time—initiated a shift for the better. He became less defensive and more open to the idea that some of his behaviors needed to change. The process raised the possibility that issues could be talked about, rather than acted upon.
The discussion took place in short increments of time over two different days, giving him a chance to think things over and assimilate what had been talked about. The idea is to allot time to the process, to build the relationship, and to follow up on any openings to explore the child's behavior, rather than to rush into starting the actual intervention.
In consultation with Tim, we simplified the goals of the collaboratively developed plan to two: "Following directions" and "showing respect." I find that it's generally more effective to limit a plan to no more than two goals, as almost any oppositional behaviors can be encompassed by these categories and it keeps the plan from becoming unwieldy. As noted, Tim was receptive to the idea that he needed to improve on following directions. He was less inclined to acknowledge that he was disrespectful, but specific examples began to persuade him. Grudgingly, he agreed to give it a try. Again, it was an opening, a different starting point, compared with earlier, more rote approaches.
We framed the plan as a teaching tool, not a mechanism for showing him how "bad" his behavior was. Instead of receiving feedback only when he'd behaved oppositionally, the agreement was that each teacher who had him in a class would provide him with 60 to 90 seconds of behavioral feedback at the end of the class. For a boy whose life seemed to swirl around him, the predictability of this aspect of the plan would be instrumental in helping him stay with it. Another purpose of the feedback sessions was to give him a picture of what he looked like when he was on task. Teachers were initially concerned that this would be too time-consuming, but they quickly came around to the idea when they understood that children with Tim's profile tend to be more successful when the feedback is consistent and predictable, and that we'd only implement the plan for two weeks before we'd stop and evaluate it.
Tim could now earn (or "not earn") rewards twice a day, so that he could have the opportunity to "turn things around" as each day continued. Checkmarks, rather than emotionally loaded smiley faces or stars, were employed to let him know how he was progressing. We modified the plan to include "reminders" rather than "warnings" when he showed signs of inappropriate behavior. In my experience, giving a warning is a red flag to an easily aroused child, tending to escalate an already tense situation.
Each class period was broken into three blocks in which he could earn a checkmark. The "beginning" served as the initial transition period, the "middle" was the workblock itself, and the "end" was the closing time. In this way, Tim and his teachers could clearly see when he did well and when he struggled. The clarity of this structure allowed Tim to predict when he'd receive feedback on his behavior and anticipate consequences. He was bolstered by the agreement that, as much as possible, his plan would be kept confidential from his peers. Despite his brashness and aggression, he was sensitive to perceived slights, so he gained a sense of security, personal control, and self-respect from knowing exactly how the process for using the plan would unfold and that it was confidential.
Rewards, whether in school or at home, need to be clear and practical, and they must motivate initial and ongoing participation. Many children, especially those whose behavior is motivated by the need for control, prefer a menu of rewards, so they can make a choice on any particular day. A child of Tim's age might be offered computer time, a chance to draw, the opportunity to build something, access to a "grab-bag" of items (including markers, pens, and baseball cards, but no food items), or some other constructive activity that's easy to deliver and monitor. For Tim, a hands-on boy with a keen interest in computers, establishing the choices was easy: he wanted a break to work on the computer at midday and access to the grab-bag at the end of the day. This was a good arrangement for his teacher, too.
Tim made good progress, and increasingly earned the 75 percent of checkmarks needed to earn his next reward. Until then, he'd been incapable of linking his behavior to the established consequences, at least in the split second of its occurrence. This is a common trait for people with severe AD/HD and corresponding oppositional behavior. With immediate consequences in view, however, he could begin to make this connection.
At the end of the two-week trial period, he asked to continue working with the plan. It helped him greatly to know that if he proved unable to earn rewards during the morning, he could "turn it around" and earn them during the afternoon. He put energy into learning to slow down his impulsive responses and trying to appear less hostile. After he'd begun to have more success in the classroom, his father enrolled him in a social skills group. The boy's improvement in school seemed to give the father more faith and trust in the counselor's recommendations.
Tim's was a success story, but this sort of intervention doesn't always lead to such positive change, notably in children who experience ongoing trauma and whose lives are unsafe. Yet even when it doesn't work, trying it for two weeks can elicit a great deal of information about the child. We can determine, at a fundamental level, if he or she can participate in it. We can explore whether the predictable meeting time with a significant adult helps build a sense of relatedness and containment. We can discover whether there are patterns to when the child experiences success or failure. At times, the plan serves as much as an informational tool as an agent of change.
Overall, what generates an opening for children like Tim to be able to change may be the relational component of having regular, nonjudgmental assessment meetings with the teacher, along with the structure and consistency of the plan. Recurring feedback, given in a positive tone and style, helps children learn how to reflect safely on their behavior. All these features offer success to children with histories of failure.
James Levine, Ph.D., is the founder and director of James Levine & Associates, a multidisciplinary consulting and psychotherapy company in western Massachusetts. A paperback edition of his Learning from Behavior will be published in December 2008.
CategoriesClinical Skills & Experience Kids & Teens
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