Middle School and Disorder

Oppositional defiant disorder falls within a new classification of disorders known as "Disruptive, Impulse-Control, and Conduct Disorders" in the DSM-V (American Psychiatric Publishing, 2013, p. 15). In prior editions of the DSM, including its most recent predecessor the DSM-IV-TR, many of the disorders in this category, including oppositional defiant disorder, were classified as "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence." Problems with self-control are the primary characteristic linking together the Disruptive, Impulse-Control, and Conduct Disorders. Moreover, the DSM-V updated the criteria for oppositional defiant disorder so that symptoms are grouped into three types including angry/irritable mood, argumentative/defiant behavior, and vindictiveness (American Psychiatric Publishing, 2013). Therefore, both mood-related and observable behaviors are part of the diagnostic criteria.

Oppositional defiant disorder symptoms "occur commonly in normally developing children and adolescents," warranting scrutiny on the part of clinical professionals for misdiagnosis (American Psychiatric Publishing, 2013, p. 15). For example, the child must exhibit the behaviors listed to at least one individual who is not a sibling (Reynolds & Kamphaus, n.d.). Frequency of behavioral outbursts is also an integral part of the diagnostic criteria. Age is factored into the diagnostic methodology. For example, children under the age of five require behaviors exhibited "most days for a period of at least six months," whereas children older than five years have to exhibit the behavior at least once a week for a period of six months (Reynolds & Kamphaus, n.d., p. 1). The behaviors are linked to environmental distress, which inhibits the credibility of the disorder.

Some examples of oppositional defiant disorder include a child who misbehaves in class, who acts aggressively toward classmates, or who acts aggressively towards parents. It is a "leading cause of referral for youth mental health services," and lifetime prevalence of the disorder is about 10%, slightly more for males than females (Nock, Kazdin, Hiripi & Kessler, 2007, p. 703). Comorbidity with secondary mood disorders, like anxiety, as well as substance abuse, has been noted in the literature (Nock, Kazdin, Hiripi & Kessler, 2007). However, comorbidity with attention deficit hyperactivity disorder is the most common with "roughly half of the children with ADHD" being diagnosed with oppositional defiant disorder too (Lubit, 2015).

The total number of sessions I would want to have with a middle school student with oppositional defiant disorder would depend on a number of factors including when the diagnosis was made, whether there were concurrent or comorbid issues, and the extent of the problem. I would also assess whether the diagnosis was made legitimately or not, and then I would aim to meet daily or at least three times per week with the child. The reason for the high level of frequency for initial interactions would be primarily to establish trust. I would also want to work with the child's psychologist, and find out if the child was taking medications. I would also want to work with the parents, and attempt to interject family counseling sessions at least once per week. Given the effects of oppositional defiant disorder on parents and teachers, it would be helpful to observe the child in as many social contexts as possible and provide the means for the child to exercise positive behaviors and self-control. I would also attempt to acquire a mentor for the child, so that the child could model his or her behavior after a positive role model.

The goals of each session would be to engender ongoing trust, improve the child's sense of self-control and confidence, and impact the child's behavior with measurable results. These would be the main goals because it is important to frame oppositional defiant disorder as something that benefits from long-term therapeutic intervention as opposed to quick fix solutions. I would also want to work with the parents to make sure that the home environment was not causing some of the problems, and to minimize any triggers for the child's feelings or behavior. I would also want to use art, music, and movement therapy in conjunction with talk therapy because the child might benefit from self-expression and new learning opportunities not typically provided at school or home. Because the child is in middle school, I would empower the child to make decisions related to how the course of treatment would progress.

The counseling approach I would use would be humanistic with cognitive-behavioral methods too. I would choose this approach because I believe it is important to use group therapy, too, as Lubit (2015) points out children with oppositional defiant disorder benefit especially from group therapies. It becomes important to reward good behavior regularly, and to counsel parents on to how to change their behavior at home so that their child is rewarded for good behavior. Rewarding good behavior is only one of the parental modifications I would recommend. As Lubit (2015) notes, "treatment is conducted primarily with the parents; the therapist demonstrates specific procedures to modify parental interactions with their child. Parents are first trained to simply have periods of positive play interaction." Shifting the focus to the parents shows how responsibility for the child is shared between the role models at school and at home.

Group counseling for middle school students has proven effective, and therefore I would recommend group therapies at least once per week. The child can learn a lot from peers, and gain social skills essential to changing attitudes and behaviors. The goals and objectives for each group session would depend on the type of intervention. Some interventions would be art, music, or movement-focused group therapies, allowing the participants to use structured activities to discover new ways of communicating and interacting. Focusing on building mutual trust, support, mutual empowerment and collaboration, the therapist can create a learning environment that offers what the child needs. Additionally, the group sessions can be observed by the parents, who can incorporate the tools and techniques of communication into their domestic interactions.