Journal Entry

I believe this patient to have Oppositional Defiant Disorder.  This patient is within the guidelines of the DSM-5 criteria.  According to Criteria A, the patent must display a pattern of an angry or irritable mood, a behavior that displays defiance or argumentativeness, as well as vindictiveness (American Psychiatric Association, 2013). Criterion B states this disturbance is in correlation with the individual’s distress or that it impacts the person negatively (American Psychiatric Association, 2013). Lastly, Criterion C states these behaviors cannot be contributed to a psychotic episode, or other disorder (American Psychiatric Association, 2013).

This patient displays anger and irritability and verbalizes being resentful of being there.  She is defiant and is argumentative with the provider who is typically viewed as an authoritative figure. She also refuses to comply with treatment and the rules.  She displays vindictiveness in the form of withholding information from the therapist.  Her symptoms are moderate in that they are present in at least two different settings.

Therapeutic Approaches

Through combined approaches, this disorder can be addressed with parenting modifications, social-emotional skills training, and if needed, psychiatric medication (Treatments for Oppositional Defiant Disorder in Children, 2020). Parenting modifications include fostering a healthy and loving relationship between the parent and child; creating healthy boundaries and rules; being consistent in ignoring annoying behaviors while praising good behaviors (Treatments for Oppositional Defiant Disorder in Children, 2020). The Social-emotional skills training includes implementing skills for the identification and management of feelings, and strategies for decision making that are not based on emotions (Treatments for Oppositional Defiant Disorder in Children, 2020).

Lastly, if necessary, I would trial a psychiatric medication for the patient.  There are not medications for ODD specifically, but the symptoms are treated (Treatments for Oppositional Defiant Disorder in Children, 2020). There are stimulants such as methylphenidate or dextroamphetamine for ADHD (Treatments for Oppositional Defiant Disorder in Children, 2020). There are also escitalopram or fluoxetine for depression and anxiety (Treatments for Oppositional Defiant Disorder in Children, 2020). Other medications that can aid with disruptive behaviors include guanfacine, clonidine, or aripiprazole (Treatments for Oppositional Defiant Disorder in Children, 2020). Medication should not be used as a standalone treatment (Treatments for Oppositional Defiant Disorder in Children, 2020).

For this patient specifically, I would implement the first two interventions prior to adding in a psych medication.  I would like to gauge the family dynamic and the patient’s emotional skills prior to adding a medication.  But, if at the second appointment she still had such aggressive symptoms, I would begin the patient on escitalopram 5mg, PO daily for three days then titrate to 10mg PO daily.  I would then recheck the patient in two weeks to make sure she wasn’t having any significant side effects.

Expected Outcomes

The expected outcomes for this patient would benefit the entire family.  The family may benefit from stronger stability and healthier boundaries, less chaos, or a more caring environment. This can be seen or reflected in children’s behaviors.  I would also expect that with proper tools, social factors such as disagreements with other children, would also be overcome for the benefit of the patient (ODD, 2020).  It was once believed that a child could “outgrown” ODD , however this has been unfounded and symptoms can occur up to an individual’s later years (ODD, 2020). If the patient needs to have medication on board to help, I would expect at least a partial remission if not a full remission of symptoms.

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