Introduction of the Client
Bobby is a White fourth-grader who is nine years old. He resides with his divorced mother, who manages operations at a nursing facility. Bobby’s father does not provide for Bobby’s children and has a significant alcohol use disorder. Bobby struggles at school by being rebellious and resistant when complying with the regulations in class and finishing his homework. In addition, he seems to struggle with self-control when angry, and he can be physically and verbally hostile to others.
Bobby generally shows disrespect for those in positions of power. Due to his disruptive and unruly behavior, he struggles with accepting responsibility for his decisions and frequently places the blame elsewhere when the reprimand is applied. Following his first three weeks of school, Bobby’s tutor, Ms. Mathews, becomes alarmed about Bobby’s conduct and refers him to counseling.
DSM-5 Diagnosis
Bobby has a disruptive behavior disorder (DBD), particularly Oppositional Defiant Disorder (ODD), which is designated as (F91.3), and Parent-Child Relation Problem (Z62.820), according to the data presented. Oppositional defiant disorder is a form of childhood maladaptive behavior illness characterized by issues with attitude and self-control (Mayall et al., 2022).
The fundamental characteristic of ODD is a recurring pattern of irritability, contentious or defiant conduct. A trend of accusatory manner, confrontational conduct, or spitefulness enduring at least six months, as shown by at least four signs from any of the presented classifications, and manifested when interacting with at least one person who is not a sibling, is what criteria A defines as this disorder. This condition is satisfied if the child satisfies criteria A1 through A8, as listed below.
- Easily becomes angry.
- Is readily offended or frequently touchy.
- Is frequently enraged and bitter.
- Often disputes with superiors or, like kids and teenagers, with grownups.
- Often disobeys orders from authorities or the law or refuses to follow the rules.
- Often irritates others on purpose.
- Often holds others accountable for faults or bad behavior.
- Has shown spite or retaliation at least 2 times in the last six months.
Bobby exhibits the signs listed in this category; he frequently throws angry outbursts, frequently quarrels with adults, refuses to comply with what adults direct, and constantly debates the validity of and disobeys rules. Moreover, he acts to irritate or annoy others, accuses others of his misdeeds or errors, and is easily irritated by others. Furthermore, Bobby frequently displays an irritated demeanor and speaks angrily or negatively.
To differentiate between conduct that falls within reasonable bounds and a problematic habit, the permanence and recurrence of these habits serve as criteria for diagnosis. These guidelines for intensity provide guidance on the nominal frequency required to characterize symptoms (Arias et al., 2021). However, additional considerations, like if the severity and frequency of the tendencies fall beyond the scope that is typical for the person’s developmental stage, gender, and heritage, must also be taken into account. Bobby meets this requirement since he exhibits all of these behaviors.
Criterion B of this diagnosis states the person’s abnormal behavior is connected to their own or others’ discomfort in their immediate social environment, such as their family, friends, or coworkers. Additionally, this disruption harms how social, scholastic, occupational, and other key aspects of functioning work (Oppositional defiant disorder (ODD), 2021). When Bobby was six years old, his mother claims he developed this irritated behavior due to his father’s neglect and history of being cruel while intoxicated. His mother laments how his hostile actions make her feel at home. His teacher frequently complains about how his obnoxious behavior at school impacts other students. Bobby meets this criterion since his behavior is detrimental to how his home and school function, and he developed this disorder due to family pressure.
Criteria C of this diagnosis states that the practices do not just happen because of a deranged, drug-using, dejected, or bipolar ailment. Moreover, the measures for violent attitude dysregulation condition are not fulfilled (Oppositional defiant disorder (ODD), 2021). Bobby does not have bipolar disorder, depression, or a drug or alcohol addiction. His actions fall within the Mild, Moderate, and Severe categories. His problems only manifest at specified times, such as at school or home, so his conduct is modest. As his symptoms appear in three or more settings—discussing with his mother, his teacher, and the counselor—his problem is serious. Bobby satisfies this requirement because his behavior is mild, with at least two scenarios in which his signs manifest.
The Parent-Child Relation Problem is a term used to describe the issues that might arise in relationships and interactions involving a parent and kid. Such an issue may arise at any point in a child’s development, but adolescence is the most likely time for it to do so (Z62.820 parent-biological child conflict, 2022). Criteria A evaluates whether there has been a recent month of parent-child relationship dissatisfaction as shown by any of the following: a persistent sense of discontent, ideas of a child fleeing, and felt need for specialized therapy. For Bobby, this criterion is demonstrated by a chronic sense of sorrow; according to his mother, he experiences moments of anguish.
Criterion B states that the interpersonal discontent has a massive effect on behavioral, intellectual, or emotional systems. This interpersonal discontent is indicated by at least one of the factors listed below for at least any of the spouses: severity of behavioral, cognitive, and emotional symptoms is evaluated (Diagnostic criteria for relational problems).
Bobby meets this requirement, as shown by his father’s behavioral symptom, which shows a persistent absence of helpful or positive behaviors. A parenting issue does not provide a better explanation for the symptoms under criterion C. Bobby meets this requirement since his father is an ineffective parent in addition to showing maladaptive behaviors.
Differential Diagnoses
Conduct disorder, depressive and bipolar disorders, social anxiety disorder, disruptive mood deregulation disorder, intermittent explosive disorder, language disorder, and attention-deficit/hyperactivity disorder are among the possible differential diagnoses for the oppositional defiant disorder seen in Bobby.
Oppositional Defiant Disorder
Behavior issues that put a person at odds with grownups and other people in authority, such as parents, teachers, and work supervisors, are linked to conduct disorders and ODD. ODD symptoms are milder than those of conduct disorder and do not entail aggression toward living things, a history of theft or deceit, or a history of destroying property. (Pijper et al., 2018). ODD also involves emotional disruption issues, such as anger and irritability, which are not covered by the conduct disorder diagnosis criteria.
Depressive and Bipolar Disorders
Both bipolar and depressive disorders can cause irritation and bad effects. However, ODD must not be diagnosed if the signs only manifest during a mood disorder. Additional mental health issues, such as depression, may coexist or emerge in kids with ODD. Since bipolar disorder can involve depressive episodes, the two conditions are sometimes confused. A diagnosis of depressive bipolar disorder should be done when a person exhibits low mood, apathy or reduced concern in enjoyable activities, regret or unworthiness emotions (Gautam et al., 2019). This diagnosis is also crucial for symptoms like energy deficiencies, poor concentration, variations in appetite, movement disorders or agitation, sleep problems, or suicidal tendencies.
Social Anxiety Disorders
Despite the frequent co-incidence of oppositional defiant disorder and social anxiety disorders (SADs), ODD must be separated from disobedience since a fear of being negatively evaluated characterizes SADs. Moreover, stress may trigger ODD-like signs such as aggressiveness, defiance and poor intrapersonal relations (Nordahl et al., 2018). By description, anxious individuals may be grouchy, worn out, or easily upset. Worried children often exhibit their teeth and claws, close down, or refuse to cooperate when they feel threatened or their tension levels rise.
Disruptive Mood Deregulation Disorder
Both disruptive mood deregulation disorder (DMDD) and ODD exhibit signs of recurrent temper tantrums and depressed mood. However, compared to people with ODD, people with DMDD have more extreme anger eruptions regarding their severity, regularity, and comorbidities. Hence, only a tiny proportion of kids and teenagers with traits suggestive of ODD would be given the DMDD diagnosis (Winters et al., 2018). Even though all ODD requirements are fulfilled, a diagnosis of ODD is not made when the mood disturbance is serious enough to satisfy DMDD criteria.
Intermittent Explosive Disorder
Intermittent explosive disorder and opposition defiant disorder have many traits, although they can differ significantly in other ways. High rates of rage are a characteristic of the disruption, impulse control, and behavioral disorders, which include intermittent explosive disorder (Radwan & Coccaro, 2020). Nevertheless, those with this disease exhibit severe anger against others that do not fit the ODD diagnostic criteria. An assessment of ODD in people with intellectual disabilities is only made if the defiant behavior significantly exceeds what is typical for people of the same maturity level and degree of mental retardation.
Language Disorder
ODD should be differentiated from a lack of adherence to instructions brought on by a problem with language understanding, such as hearing loss. Even though language disorder signs differ from ODD, Children with disruptive behavior disorders usually seem to have less fluency in language than their peers of the same age (Ogundele, 2018). A youngster who suffers from verbal ability impairment has difficulty speaking. The youngster might be able to comprehend what others are saying. Nonetheless, individuals struggle to speak and frequently find it difficult to convey their feelings and thoughts.
Attention-Deficit/Hyperactivity Disorder
Attention-deficit/hyperactivity disorder (ADHD) is a typical childhood cognitive disease that manifests as fidgety or hyperactive behavior, difficulty maintaining concentration on tasks or awaiting a response, and issues with obeying laws in various contexts. The doctor should screen ADHD as the leading factor of oppositional behaviors because ADHD and ODD often coexist (Sagar et al., 2019). Additionally, ADHD and autism frequently exhibit oppositionality, particularly during times of shift in the pattern or another sensory disturbance.
Parent-Child Relationship Problem
Intrinsic Child Problems, Troublesome Parenting by the Intended Parent, and Controversial Parenting by the Affiliated and Allegedly Preferred Parent are among the differential diagnoses of the Parent-Child Relationship Problem. Controversial Parenting by the Affiliated and Allegedly Preferred Parent involves triangulating the kid into a domestic conflict (sometimes called placing the child in the middle). Through forming a cross-generational alliance involving the kid, the aligned parent and the opposing parent, it is accomplished (Bernet, 2020). A cross-generational alliance also exhibits a distinctive pattern of signs, notably the concepts of an inverted hierarchy and the lack of stimulus control exerted by the intended parent’s conduct over the children’s actions.
The child’s symptoms could be brought on by a condition the youngster already has, like emotional regulation challenges, autism spectrum disorders, or ADHD. In order to validate or refute any probable intrinsic child difficulties connected to the kid’s clinical manifestations, one set of evaluation questions will therefore involve meticulously obtaining data (Pereira-Sanchez et al., 2021).
Several inquiries concerning school behavior (conformity of symptoms showcased all over contexts) and background of explosive-angry outbursts could rule out this intrinsic-child origin of the parent-child dispute after divorce. Innate childhood emotional compliance issues can be a contributing factor in parent-child disagreement.
The intended parent’s terrible behavior may bring on the parent-child rivalry, and the child’s troublesome reaction to the designated parent’s problematic childrearing may also contribute, according to the following collection of differential diagnostic options. Evaluating the Behavior Chain in Parent-Child Controversy uses a particular kind of analytic inquiry known as the behavior-chain sequence in which both participants are requested to recount the engagement procedure during earlier occurrences of parent-child dispute.
Behavior chain interviews are essential for identifying the root of parent-child conflict in divorces with high intensities of animosity as well as the attachment-related disease (Pluhar et al., 2020). The behavior-chain assessment method of Applied Behavioral Analysis must be used by all mental health providers evaluating attachment-related pathologies around divorce.
Conceptualization of the Client
Partnerships, media platforms, and interpersonal interactions are influenced by an individual’s genetic makeup and surroundings. A person’s childhood is a crucial period in their life because it is full of various modifications that impact their entire being and identity. A person’s biology precisely examines their brain and how it functions normally or abnormally (Vermette & Doolittle, 2022). When examining a person’s psychological makeup, it is crucial to consider their behaviors. It can be hard for someone even to identify their actions.
The underlying problem behind the odd behavior is that it serves to cause chaos inside of them, which has a daily impact. It is crucial to understand that there is a stigma associated with mental disorders in several civilizations. Information will be collected about the cultural and social facets of family ties, financial security, and educational history (Vermette & Doolittle, 2022). Faith, religious coping and aid, spiritual health, and spiritual want are general categories for evaluating various facets of spirituality.
Client’s Strengths
One of Bobby’s strengths is his excellent communication and affection for animals, which he only sometimes seems to be able to achieve with individuals. Bobby’s rebellious and belligerent actions show his strongest quality, his desired determination. Youngsters that engage in disruptive and rebellious activities are adamant about not abiding by the regulations laid forth; rather, they prefer to forge their course and carry out their personal preferences.
Client’s Weaknesses
Contrary, Bobby’s challenges include his incapacity to express his demands and converse. He decides to battle every internal battle by himself, which is daunting for a child of his age. Poor dialogue participation skills present another challenge, making it difficult for a counselor to communicate with him.
Biological Aspect
When examining Bobby from a biological perspective, no evidence indicates a tragic experience, like brain damage, would describe the signs of his disease. Once his mum told him his father would not return, he appeared to have developed symptoms like aggression and disobedience. From a psychological standpoint, Bobby believes that while considering internal conflict within oneself, the psychodynamic perspective is the most appropriate. His father’s absence from his life has affected the way he behaves.
Sociocultural Aspect
From a societal and cultural perspective, Bobby can be going through an internal struggle among his family, culture, and regular activities relating to his classmates and participating in society. He is more at ease around animals than he is with people. He is so socially awkward that he will not talk to his mother. Bobby occasionally wants to be near his mother but only sometimes seems to understand how to accomplish this. Neither the teacher, Bobby, nor his mother discussed any spiritual issues throughout the interview; neither did they discuss their religious practices.
Suggested Treatment Care Recommendations to Consider
Crisis Needs
Although the client does not now pose a great danger of suicide, they should be constantly watched. The worst signs should become more bearable as soon as you begin psychotherapy. To avoid major long-term difficulties, Bobby requires crisis assistance. A patient, soothing, and skillful strategy for long-term crisis resolution can considerably increase this procedure’s success.
To alleviate immediate suffering, regain physical and mental equilibrium, and implement prosocial management techniques, the counselor may employ psychological first aid (Ishila et al., 2022). Positive effects of crisis intervention include reduced stress, if any, and enhanced problem-solving. Bobby requires some space to express regret and come to terms with the past because the healing process might involve feelings of sadness and pardon. A therapeutic connection and compassionate reaction should also be provided to uphold the patient’s rights and make room for crucial follow-up care.
Case Management and Referral Needs
The client does not need housing, financial support, or employment aid. He needs a professional evaluation, treatment strategy, and a psychiatrist’s urgent reference. Bobby may be referred for various reasons, including assessments of his abilities and shortcomings, assessments for cognitive problems, including smartness, abnormalities, cognitive impairment, or learning difficulties, and diagnoses of psychiatric disorders. In order to examine Bobby’s mental well-being and performance, a psychiatrist would need to gather information on him. Bobby’s case management required his mother to prepare him for the test.
Furthermore, his mum should make sure he has enough sleep, food, and water. The mother should write down any present-day worries or ideas before the assessment so they can be communicated with the assessor. These documents should detail the child’s development starting at a young age; this will prevent her from forgetting crucial details during the conversation. Bobby’s mother should bring the completed information forms, prior academic transcripts, and initial evaluations. As a component of the data necessary for case management, caregivers are also questioned in the assessment process and provided checklists to complete.
Type of Therapy/Treatment Recommended
Family-based therapy is most commonly used for managing oppositional defiant disorder. However, various methods of motivational interviewing and child and parent education might be a component of the therapy. Any additional concerns, like a developmental disorder or psychiatric condition, can lead to or worsen ODD signs if left untreated. Anger management treatment, play therapy, family counseling, and psychosocial instruction are other treatment modalities that may be beneficial for treating ODD.
ODD may ruin a family as a whole. Family members learn better survival and connection techniques through family counseling. Parent-child interaction treatment is counseling that improves parent-child communication while encouraging good parenting practices. According to some studies, it can enhance family life for kids with ODD (Mahmoodi & Mousavi, 2019). Parents and kids can cooperate to find solutions to the issues ODD brings by using a different strategy called cooperative problem-solving.
Anger management is a common problem for kids who have problems managing their emotions. Approaches for calmness, goal-setting, efficient problem-solving, trigger detection, and understanding of repercussions can all be learned through anger management. ODD can occur in adults but is more frequently identified in youngsters. For young children who are having difficulty understanding or expressing their emotions, play therapy offers an alternative form of expression (Ashori & Yazdanipour, 2018). Children may acquire new coping mechanisms, process feelings, and comprehend their conduct via play.
Individuals with ODD struggle more to solve social problems like disagreements with a buddy than those without ODD. Healthy relationships can be facilitated and problems at work and school can be avoided by encouraging creative problem-solving strategies and teaching social skills (Green et al., 2021). Additionally, Bobby might profit from receiving trauma treatment because, in my opinion, some of his acquired violent behaviors against other kids are a consequence of his prior trauma.
Parent-child interaction therapy (PCIT) may be employed to treat Parent-Child Relationship Dysfunction. PCIT is a family-focused, behavior-based treatment that enhances the parent-child bond via contact. In this approach, child-focused interaction can encourage the development of useful parenting abilities, reduce behavioral problems, and create closer family ties (Woodfield et al., 2021).
This strategy might be helpful for parents looking for treatment to solve those problems in their kids or to enhance their relationships with them. PCIT raises the feeling of security and safety in the child-parent relationship while also enhancing the bond between the kid and his parent, enhancing both the child’s and the parent’s general psychological well-being, giving both the kid and caregiver coping techniques, and strengthening the child-parent connection.
Care Plan
Medications
Type of Medication(s) Recommended
Atypical antipsychotics such as aripiprazole and risperidone might be recommended. However, the ability of medicine alone to treat ODD has not been established. To treat comorbid diseases like ADHD, depression, and mood disturbances, as well as to control certain behaviors, drugs may be an important component of an all-encompassing treatment approach. When coexisting conditions are effectively managed, ODD treatment is typically more effective (Dedousis-Wallace et al., 2022).
For instance, it has been demonstrated that medications used to cure children with ADHD can reduce behavioral symptoms when ODD and ADHD interact. Medication with anti-depressants and anti-anxiety drugs has been shown to help decrease the behavioral signs of ODD in children and teenagers with a psychiatric illness or stress.
Side Effects the Medications Might Cause
Atypical antipsychotics can have unsettling side effects such as higher levels of cholesterol, muscular rigidity, slow and uncoordinated mobility, spontaneous tremors, significant weight growth, and an enhanced likelihood of developing type 2 diabetes.
Related Counseling Psychoeducation
The therapist should give patients counseling and guidance about the drug, including how to handle adverse effects. Before beginning therapy, the child and parent must be informed of the dangers of using an atypical antipsychotic. A benchmark for weight should be developed, and the patient must be regularly checked for body weight and metabolic parameters since these drugs are linked to considerable gaining weight and metabolic alterations. The prescription instructions for each medicine include specific suggestions for surveillance. Combining antipsychotic drugs is not recommended because the interaction of a signaling molecule and an inhibitor causes unexpectedly high levels of receptor activation (Fountoulakis et al., 2020). The counselor should also discuss the dangers of stopping without a doctor’s approval.
Self-Reflection and Conclusion
I might not be capable of linking to Bobby in a supportive way. Bobby is not an adult; kids are a completely different species and require a different kind of relationship. Talking, acting, and behaving are different for a 9-year-old than a 16-year-old. In addition, since I do not have kids, therapeutic relationships with them are different for me. Moreover, setting boundaries for conduct without restricting the youngster could present another difficulty. The objective is to accept the youngster I am meeting for counseling as honestly as possible. I have to put up with Bobby’s wild behavior because I want to reassure him that he is fine. As a result, it will be difficult to establish a cordial connection with the client while being cool and steady while imposing behavioral limitations.
Without boundaries, working with Bobby will be challenging. It will be challenging to prevent me from getting to know the client personally. For instance, in Bobby’s situation, I need to establish a close bond with Bobby before he can freely connect with me. Furthermore, being unduly influenced by Bobby’s mother and instructor’s expectations and intentions will pose a further problem. If mothers, educators, and others who recommend kids for counseling did not care sufficiently to observe their kids’ suffering and understand that they require changes to occur, they would not seek assistance.
Before meeting the child, it is essential to learn about their understanding of the child, current issues, and pertinent background information. When I get the chance to see Bobby for counseling, it will be challenging to keep in mind the aspirations, anxieties, and demands of his teachers and those of his mother. Being authentically engaged with the child while putting the referrer’s goal to one aspect will pose the greatest task.
On the other hand, the client’s lack of social abilities will cause him to struggle with me. These subpar abilities typically require putting aside interruptions and concentrating on the speaker. A child who lacks social skills is unable to concentrate on the presenter. An older person can initially believe that a kid is not paying close attention. These kids would need to interject to listen to an individual. In some situations, Bobby might not take what was stated well; rather, they might react differently depending on their instincts.
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