Thursday, October 15, 2009

Tackling ODD with Tortuga

We have been seeing real progress again with Tortuga. I have written some of this before but I am trying to piece together what we have been doing lately because a few of you have asked for more details. Sometimes it also helps me to write things again because I read them with new eyes even if it is something I already know. Sorry if this is a repeat but then again isn't that how this rollercoaster ride goes?

About 3 months ago we reached a crossroads with Tortuga. There were good days and bad days as with all our kids. We had reached a plateau in his progress and we were experiencing some serious downsliding. I realized we were spending much of our time redirecting him and cancelling most of our summer outings because he was so unpredictable. He would only speak to me in a disrespectful tone. He ignored me, argued constantly, didn't make eye contact, didn't follow even the simplest directions, "forgot" all of his routines (shower, teethbrushing, walking in the house, bathroom use, laundry, bedtime prep, getting dressed, etc.), yelled at me for seemingly no reason, and every request was met with contempt and non-compliance. Whenever I spoke to him he interrupted me constantly and "forgot" everything I said. He would ask for help and then get mad when I tried to help. He shot hateful looks at Corazon and Pollito every chance he got even when they weren't dealing with him. It was always "their" fault or my fault that he was being rude, obnoxious, mean or disrespectful. We were his triggers. He was also deliberately mean to both of them no matter how nice they were to him and he started making up stuff about how "bad" Corazon was. His demeanor toward me was especially "hateful" in every sense of the word including trying to physically overpower me and "bully" me with his words, tone, attitude, and demeanor. While I was non-plussed by most of it I was also getting scared for him. He is 10 and quickly approaching an age where hormones and social pressures and peers will become more influential and I needed to try something else.

Oppositional Defiance Disorder (ODD) is certainly one of Tortuga's "diagnoses"and many of his behaviors "fit the bill." When he first came to us he had ALL of the behaviors associated with ODD. According to the Mayo Clinic and other sources kids with ODD exhibit Negativity, Defiance, Disobedience, and Hostility directed at authority figures. For him it meant we were subjected to temper tantrums, excessive argumentativeness with his teachers and his parents, refusal to comply with adult requests/rules, deliberate annoyance of others at home and school, blaming others for his own mistakes and misbehavior, easily annoyed especially by parents and siblings, anger and resentment, spiteful or vindictive behavior, mean and hateful talking when upset, aggressiveness and spite toward peers and revenge seeking (for real or imagined offenses), difficulty maintaining friendships and academic problems.

But he also had other "diagnoses" (12 or 13 to be precise) that had symptoms that overlapped with ODD. Over the years he had been diagnosed with ADD, learning issues, depression, anxiety disorder, RAD and even a suspicion that he might be bipolar. It was difficult to figure out what was connected to these other issues but in all honesty I wasn't particularly interested in the labels. I was concerned with how to help my child. We took him off all his meds because we wanted to know what we were dealing with plus he had been medicated since he was 3 and I figured his brain had to have been affected by all this. One of his therapists determined that he didn't have ODD he just needed to be heard and understood. She worked hard at building a trusting relationship with him via play therapy and he triangulated us to no end and made our lives a living hell for the 24-48 hours after each session. We eventually gave that up because it just wasn't helping and it was eroding all of our quality of life.

As we worked on helping him become a part of the family and address his many needs and issues I read everything I could on all his potential issues and worked to integrate them into our lives. Because the ODD behaviors has always been obvious and prevalent we have tried to use as many of the recommended parenting strategies as possible including these:

Limit consequences to those that can be consistently reinforced and last a limited amount of time
--Give effective timeouts (time ins in our case as we tried to build attachment)
--Avoid power struggles
--Remain calm/unemotional in the face of opposition
--Recognize/praise good behaviors and positive characteristics
--Offer acceptable choices to your child
--Give him some amount of control
--Establish routines and schedules
--Have specific activities to do with the child

All these things have helped but as I said we were plateauing and I was hitting the wall trying to figure out what to try next. So I spent a few days taking another "inventory" of what was happening with him, what issues he was having, triggers, when he was regulated, when he wasn't, etc. When he was in a decent mood we had a "heart to heart" about a few things so I could gather more "data." I finally concluded a few things that made sense only to me. The most important of these was that I needed to make his world very, very small. Ideally this would have been keeping him close by like I would with a toddler/preschooler (because that was what many of his reactions reminded me of). This was almost impossible because I do have a toddler and a five year old who contributed to his issues. After a few days of trying the "sticktight" approach with him things got worse. It was just too much. Anytime he saw Corazon or Pollito he lost it. He dominated ALL of my time and he was stressed and upset throughout the day and I wasn't able to serve him or any of the other children.

C. and I sat him down and told him he was showing us that he wasn't able to honor our family values--respect, responsibility, safety, obedience and caring/kindness. We told him he either didn't want to, didn't know how, couldn't do it because it was too hard, wasn't interested in doing it consistently, wasn't ready to or all of the above. It didn't matter to us what was causing it but we loved him and we knew things had to change. We told him he would no longer be expected to do any of those things and he would no longer be expected to spend any time with his siblings (Corazon and Pollito) since he vows that he hates them and the writing in all his notebooks/ papers/folders/etc. affirms this. We tried to remove all of the stressors from his day to see what would happen. I informed him that he would be taking a break from the family for an indefinite period of time. We would check in after a week and reassess. I certainly wasn't sending him away or telling him we didn't love him but I was letting him know he wasn't behaving in a likeable or loveable way to any of us.

I took away all the things he couldn't handle consistently and appropriately. No responsibility. No routines. No chores. No schoolwork (it was still summer.) No expectations. Nothing. It was similar to our earlier strategies of removing TV, video games, and other high stimulus activities. We focused mostly on meeting his most basic needs. I "overdid" all the basic "necessities." I overfed him at every meal (we still have food issues) and increased his snacks. He could go to the bathroom as often as desired, stay in there as long as desired as long as he didn't destroy anything, and made sure he had plenty to drink throughout the day. I gave him really comfortable bedding, pulled out his favorite tshirts and pjs for him to wear, got the temperature in his room "just right" for him, and played "soothing" music in his room. Each morning and each afternoon/evening I spent about an hour with just him and no interruptions (chatting, rubbing, reading to him, listening to him.) With three other kids it was really challenging to carve out two hours of uninterrupted time with him but it was essential. Our goal wasn't to isolate him but we had to take him out of all of the stressful situations that seemed to set him off.

At first he was happy with all this. He could spend hours in the bathroom, get 5-8 snacks a day plus 3 very large meals, and he was content to lie in bed and do "nothing." He was pleasant during our time together and seemed to enjoy it. When we checked in he said there was NOTHING he missed about being with the family or the other kids. He also had a few options for activities (drawing, writing, reading, puzzles, legos) or he could just lie in bed and do nothing. After about a week of this he started to "look" for reasons to be oppositional, defiant or just plain mad at me. He initially destroyed puzzles, legos, paper, pencils so we just took them away. The only consequence was that the thing he destroyed didn't get replaced. He took his meals alone or with me keeping him company but I didn't eat with him. He ate before the rest of the family so he wouldn't have to listen to the rest of us while he ate. (Being first at things is really important to him.)

He asked for schoolwork so I said we would try it as a "test." Over the next few weeks everything was a "test." If he couldn't handle it we just went back to the way things were without it. He did continue to have some meltdowns and we ignored them. When he was calm I asked him to come up with something to do to help him calm down. We settled on the shower. Whenever he would go off he would be sent to shower. The shower was an interesting experiment and has really worked for him. The water provides stimulus for him that is both positive and negative, it also muffled his screams so he could scream more freely AND it literally chilled him out.

An interesting thing started to happen about three weeks into this--he spent noticeably less time in bathroom, less need for constant water breaks, refusal of snacks and more normal portions of food. I still "overfed" him but he couldn't/wouldn't eat it. The meltdowns decreased to maybe 2-3 per week and were short-lived. He would ask to take a shower as he felt himself getting worked up AND in one of our conversations he noted (unprompted) that he had realized that hitting and destroying things made him angrier and didn't make him feel better. He even recounted conversations with his therapist (the one who didn't think he had ODD) where she told him to just hit his pillow when he got angry and he had realized that those things did not help him. Other things started to change. He stopped talking to me with an attitude, stopped interrupting me, and started saying "yes mom" and "thank you for helping me mom" each time I redirected him and I could SEE him working hard to keep his attitude in check. Yes there were slip ups but it was worlds better. So I decided to continue to "overmeet" his basic needs but increased the work on meeting more of his "safety" needs.

This is getting really long (no surprise for me) but I am going to stop here and continue this later in another post.


Carmel said...

I really appreciate you writing all this out and do hope you continue in another post. I am constantly learning new techniques from you and I thank you.

Tracey said...

Loving this! I totally have this kid in my home. Please keep writing about how you make it work. You are such an inspiration to me!

BT said...

As P approaches age 10, I worry too about the approaching onset of puberty and what effect that is going to have on the RAD.

Thank you a bazillion for this post, and I'm looking really forward to the next installment when you have the time.

Dia por Dia said...

Carmel, Tracey & BT,
Thank you for your comments. It is hard to draw the line and figure out what to write about and what not to write about. I too learn from details but it feels so public and open to misunderstanding at times. Your comments have helped me continue to try to tell this part of the story in hopes that it helps others. Thanks again.

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