PMH/505 Week 6: Disruptive Behavior and Conduct Problems, sample paper

A Five-Year-Old Expelled From Preschool: Parent-Child Interaction Therapy for Oppositional Defiant Disorder, the Parenting Components That Work and Why an Antipsychotic Is Not the Answer

[Student Name]

University of Phoenix

PMH/505: Psychiatric Management Of Children And Adolescents

Week 6 Assignment

[Instructor Name]

[Date]

The patient is a composite written for a model paper.

Tyler, 5, was expelled from his second preschool this year for hitting, biting and throwing chairs. At home, he refuses nearly every request, has tantrums lasting up to an hour and argues constantly. He lives with his grandmother, Mrs. H., who has custody because his mother is in treatment for opioid use disorder. His father is not involved. Mrs. H. is 62, has arthritis and says she is "at the end of my rope." A doctor at an urgent care clinic suggested risperidone. She asks whether it would help. The sections below confirm the diagnosis, weigh the treatments and set out the plan she chose.

Diagnosis

Oppositional defiant disorder involves a persistent pattern of angry or irritable mood, argumentative or defiant behavior or vindictiveness lasting at least six months, with at least four symptoms, shown with at least one person who is not a sibling. Tyler's pattern has lasted more than a year and impairs his education and family life. ADHD is screened and is not present; his attention is good in play he enjoys. His speech and language are age appropriate. Trauma is a central consideration: he experienced his mother's overdose at age 3, and he was removed from her care at 4.

The Trauma Question

Behavior in a young child who has experienced trauma and separation from a parent may reflect fear, insecurity and learned patterns, not only defiance. Tyler's tantrums worsen after supervised visits with his mother. Treatment must build safety and a secure relationship with his grandmother, not only reduce behaviors.

Parent-Child Interaction Therapy

Thomas and Zimmer-Gembeck (2007) conducted a review and meta-analysis of 24 studies comparing Parent-Child Interaction Therapy and the Triple P-Positive Parenting Program for caregivers of children aged 3 to 12. Both reduced parent-reported child behavior problems and parenting problems, and effects for PCIT were large when assessed by parent report. PCIT's two phases, child-directed interaction, in which the parent follows the child's lead in play while praising and describing, and parent-directed interaction, in which the parent learns clear commands and consistent consequences, strengthen the relationship before addressing discipline.

The first thing Tyler's grandmother learned was not how to discipline him but how to play with him for five minutes without correcting.

Which Components Matter

Kaminski et al. (2008) meta-analyzed 77 evaluations of parent training programs for children up to age 7 and found that components consistently associated with larger effects included increasing positive parent-child interactions and emotional communication, teaching parents to use time out, emphasizing consistency and requiring parents to practice new skills with their child during sessions. PCIT includes each of these, particularly live practice with coaching.

Tyler's PCIT

Mrs. H. and Tyler attend weekly sessions. In the first phase, she learns to give labeled praise ("Thank you for putting the block there gently"), reflect his words, describe his play and avoid questions, commands and criticism during five minutes of daily special time. The therapist coaches her through an earpiece from behind a one-way mirror. In the second phase, she learns to give one clear command at a time and, if he does not comply, to use a consistent time-out sequence. Sessions continue until she meets mastery criteria and Tyler's behavior is within the normal range on a standardized rating.

The Antipsychotic Question

Olfson et al. (2006) found that office-based visits by youth that included antipsychotic treatment increased from about 201,000 in 1993 to 1,224,000 in 2002 and that disruptive behavior disorders were the most common diagnosis, accounting for 37.8% of mental health visits with antipsychotic prescriptions. The authors noted that evidence for antipsychotic safety and effectiveness in youth was limited. For a five-year-old, the metabolic effects, sedation and uncertain long-term effects make antipsychotics a poor first choice when parent training works.

Explaining This to Mrs. H.

I tell Mrs. H. that medication might quiet Tyler somewhat but would not teach either of them new ways to respond, would add weight gain and other risks and would not address the reasons for his behavior. PCIT can change his behavior in a few months and give her lasting skills. She agrees to try it and to reconsider medication only if severe aggression continues after an adequate trial.

Supporting the Grandmother

Mrs. H. is a kinship caregiver managing her own health, grief about her daughter and the demands of a young child. She is connected with a kinship caregiver support program, respite care and her own counseling. Caring for the caregiver makes the treatment possible.

Early Progress

By the fourth session, Mrs. H. reports that Tyler asks for special time each evening and that tantrums have shortened from an hour to about 20 minutes. She says she had forgotten how to enjoy him. Early gains in the relationship often precede reductions in defiance, and naming them helps a tired caregiver stay with the treatment.

Physical Limits of the Caregiver

Mrs. H.'s arthritis makes it hard for her to carry Tyler to time-out. The therapist adapts the sequence so that she uses a time-out chair near her and a backup privilege loss rather than physical guidance, keeping the procedure consistent and safe for both of them.

Preschool Placement

Tyler qualifies for an early childhood special education evaluation through the school district. A therapeutic preschool placement with small classes and staff trained in behavior support replaces the settings from which he was expelled. His PCIT therapist shares strategies with his new teacher.

Visits With His Mother

Supervised visits continue, as directed by the court. Mrs. H. prepares Tyler with a picture schedule showing the visit and his return home and plans calm activities afterward. His mother is invited, when her treatment allows, to learn the same PCIT skills.

Sleep and Routine

Tyler goes to bed at different times depending on Mrs. H.'s pain and energy. A fixed bedtime, a picture routine and a short story each night give his evenings structure, and tired children have more tantrums.

Measuring Progress

The Eyberg Child Behavior Inventory is completed by Mrs. H. at the start, midpoint and end of treatment and his teacher completes a matching rating form. Daily tantrum counts are recorded on a simple chart that Mrs. H. brings to every session for review with the therapist.

Prognosis

Early-onset disruptive behavior predicts later conduct problems, academic failure and substance use if untreated. Effective intervention at five, while patterns are still forming, offers the best chance to change this path.

Conclusion

Tyler's oppositional defiant disorder occurs in the context of early trauma and separation from his mother. Meta-analytic evidence supports parent-child interaction therapy, and its key components, positive interaction, consistent discipline and live practice, are those most strongly linked to success. National data show antipsychotics are frequently prescribed for disruptive behavior despite limited evidence, so parent training, caregiver support and a therapeutic preschool form his plan.

References

Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36(4), 567-589. https://doi.org/10.1007/s10802-007-9201-9

Olfson, M., Blanco, C., Liu, L., Moreno, C., & Laje, G. (2006). National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Archives of General Psychiatry, 63(6), 679-685. https://doi.org/10.1001/archpsyc.63.6.679

Thomas, R., & Zimmer-Gembeck, M. J. (2007). Behavioral outcomes of Parent-Child Interaction Therapy and Triple P-Positive Parenting Program: A review and meta-analysis. Journal of Abnormal Child Psychology, 35(3), 475-495. https://doi.org/10.1007/s10802-007-9104-9