How do you decide if her symptoms are more indicative of ODD or CD?

Question

DSM Diagnosis
313.81 Oppositional Defiant Disorder
315.0 Reading Disorder
315.1 Mathematics Disorder
315.2 Disorder of Written Expression
317 Mild Intellectual Disability

Rationale
Oppositional Defiant Disorder was diagnosed due to the following behaviors that are present both at school and at home:
? Josie loses her temper easily
? She constantly argues and tests limits with adults
? She refuses to comply with classroom directions
? She is touchy or easily annoyed by others
? She is often angry as evidenced her consistent profanity and verbal assaults of staff.
Josie was diagnosed with a mild intellectual disability because of her cognitive impairment and low adaptive abilities. Additionally, the Learning Disorder diagnoses were given because, even if a person has a mild intellectual disability, learning disorders should be listed if the person’s achievements are below expected levels for his or her cognitive functioning. In her testing Josie scored in the Very Low Range in all three categories, typically near the first percentile.

Additional Information Required
A key element to help with the diagnosis would be knowledge of the early course of Josie’s behavior. There is no information about how she behaved in childhood and her early teens. What were some of the early signs that she was having problems?
Another area in which there is no information is her response to vocational skills training at school. Because Josie is 19, she needs to be prepared with job skills when she graduates from high school. We do have information that her behavior has been addressed in school by suspension, detention, and locked support. It would be important to know if there is a behavioral modification in place adapted for persons her age that emphasizes functional analysis of her behaviors, shaping, and positive reinforcement.

As with all cases of ODD and CD, family intervention remains the most effective intervention. Therefore, Josie’s parents will be given training in behavioral modification so they can apply a similar structure to the one that Josie faces at school. It is important that her parents exercise consistency in their discipline methods. The social worker needs to empower Josie’s mother to involve Josie’s father in treatment efforts and, if that fails, reach out to him herself. Josie’s mother needs more support in the home in order to follow through with requests for Josie to do chores or listen to what she says, especially in the face of Josie’s escalating anger.
Josie does seem to gain a sense of pride from assisting the teacher in the classroom. To capitalize on this, the social work intern will arrange for Josie to get a job on the school campus.
In working with people with mental retardation, it is important to alter the conditions that might trigger behavior problems (Rush & Frances, 2000). What seems to be partly contributing to Josie’s frustration is her difficulty with schoolwork. A behavioral modification plan, adapted for her age, can be put into place, emphasizing functional analysis of her behaviors, shaping, and positive reinforcement.
Working with Josie in an individual or group basis is also important for overcoming her ODD symptoms. Anger management with people with mental retardation has been proven effective in two randomized controlled trials (Taylor, Novaco, Gillmer, & Thorne, 2002; Willner, Jones, Tams, & Green, 2002). Josie should prove an appropriate candidate for such training. The focus needs to be learning to cope with stressors, and developing skills to express frustration appropriately.
Although the diagnosis of Reactive Attachment Disorder was quickly ruled out because Josie appears to have attachments (to her mother and sister, for instance) and can form relationships (her teacher, some peers), little is known about the manifestation of Reactive Attachment Disorder as youth mature into adolescence and early adulthood. Josie was given to an orphanage at 6 weeks of age. Her mother doesn’t know much about Josie’s early history but it can be surmised that her care at a Romanian orphanage was less than optimal and comprised multiple caregivers. Whether Josie formed an attachment to a caregiver in the orphanage is not known. Further, environmental deprivation may have contributed to Josie’s learning disabilities and mental retardation.

Answer 1

In conduct disorder the truancy must emerge prior to age 13 to indicate pervasiveness of the symptoms. More generally, Josie’s pattern of behaviors seem less like antisocial behaviors and more like acting out against rules and annoying people as a way of expressing her frustration or to gain attention. The client realizes that she is different from others her age (as when she calls herself stupid), has trouble expressing her frustration in appropriate ways, and has no acceptable ways to try to fit in with her peers. This might explain her bringing in a pocket knife to show off to others. Note that her social skills have been assessed at a 7-year-old level.
While she becomes violent towards staff or other students, she is not a bully nor does she initiate fights for the sake of fighting. Further, Josie does not steal, is not physically cruel to animals, has never run away, and, other than ripping down bulletin boards while being restrained, does not destroy property.