Oppositional defiant disorder

[LisaNICUrn, BSN]

Just wondering what the child/adolescent psych units do to treat their ODD patients. Not what meds or things like that but what do the nurses to do care for them when they are in the hospital. I work in an inpatient acute unit and we have a lot of patients with ODD. They end off being very defiant when they start making the unit unsafe. They antagonize other patients and cause commotion on the unit. Time and time again I just see them sent to their room, sometimes an entire day. They get bored and oppositional and argue with staff, and then end up in the "quiet room." Then after hours and hours of sitting there doing nothing, naturally the 14, 15, 16 year old child gets bored and wants out. Since they are so defiant and such an antagonist to other patients, we fight back an make him stay in his room, he fights back even more and comes out, then we put hands on or give "Emergency treatment orders" to give medication to make him stay in the room. It's a vicious cycle.

I hate it though. It's not therapeutic at all. The patients learns nothing, has nothing achieved from staff or the patient. Of course he wants to come out of his room or the quiet room after sitting there for hours doing nothing. How do you guys handle these patients on your unit? My manager is asking for suggestions. She doesn't want the unit to "punish" patients. We are not their parents, we are a hospital and we are here to help them. We are here to treat them, care for them, not punish them. But it's so hard with patients with ODD. That's who they are. Any suggestions? Thanks

[OldDude]

I am an elementary school nurse and I see ODD on a fairly regular basis. I'm skeptical of some of the diagnosis and pretty sure it was applied simply to rationalize and explain the kid's behavior. On the flip side I completely agree with the diagnosis. Early intervention is always best so the age group of kids you are receiving, real intervention associated with treating ODD will likely be impossible in the time you have them. I can't recall a child with a single diagnosis of ODD...it's always an additional dx along with something else; frequently ADHD. In many cases (on the elementary level) a therapeutic dose of the stimulant medicine like Ritalin, focalin, vyvanse, will ameliorate the ODD behavior. Otherwise I've seen an adjunct med like risperdal that has a positive contribution. A strict routine is also helpful along with the medication. Of course I'm not offering advise for medical treatment...just relaying my observations over the years. Good luck and thank you for having the grit to work adolescent psych. Hats off to you!

[UsernameNotFound, BSN, RN]

We spend a good amount of time processing with our patients and helping to put their emotions into context. I try to partner with my patients by letting them vent about what's troubling them at home or school, finding those areas where they really feel unheard or unwanted, and trying to get their buy-in on focusing there. I continue to hone my approach and can be flip-floppy depending on how the interaction goes. Often times, my patient feels their behaviors are due solely to factors outside of their control, e.g., "My mom is crazy, not me! Get her a$$ in the hospital!" or "My foster dad doesn't know what I've been through and he's not even trying to learn - he just gives me rules that don't make sense." In those cases, I go with something like, "You know what? I hear you. Sometimes we end up here because of the challenges we have with other people. If there's nothing you feel like you need to change, maybe we need to focus on something that's gonna actually be useful for you, like "how to deal with difficult people." You'd be surprised how often this can spark an alliance (however fleeting), even with hardcore kids. I also tell them that they can probably be really helpful to the younger kids in the milieu during group discussions, because they've got a story to tell. I also let them know that they can always look for me or ask for me if they start feeling "some type of way" during my shift. Sorry if that all sounds really simple or hokey. I'm still working on it, but it's what I've got for now.

Also, finding alternate activities can be helpful. For kids that just cannot bear sitting in the dayroom all day long, and really aren't about the life of crayon-coloring mandalas in the hallway either, I enlist their help. Sometimes their interests can surprise you. And we all like feeling useful. I try to find some work around the unit that can be safely done, and let them know I could really use their help with it. Even if it requires keeping an eye on them while you work, it beats de-escalating and chasing them in and out of the quiet room all day and night. I've had teenagers help me by folding unit sweatshirts (even if I then take the folded sweatshirts into the back, ball them up, and present them as a new batch to be worked on). I've had some inspect the unit, clean the baseboards with purple wipes (really!), sort print-outs and books, make lists of stuff like topics we could use for groups, get shower supplies prepared, etc.

Don't get me wrong. Some -- maybe even most -- kids with ODD aren't gonna buy what you're selling, no matter what. They will present one long behavioral management task for the duration of their stay. But I make it a personal challenge to crack them somehow. If not, nothing lost in trying.

Hope this helps somewhat. Best!