PATCHS PROGRAM PUBLIC HEALTH NURSING ADVOCATES TEACHING CHILD HEALTH AND SAFETY HEALTH CARE PROGRAM FOR CHILDREN IN FOSTER CARE (HCPCFC)
Volume 1, Issue 24		JULY 2006

Medical Information Fact Sheet

Intermittent Explosive Disorder:

Road rage. Domestic abuse. Angry outbursts or temper tantrums that involve throwing or breaking objects. Sometimes such erratic eruptions can be caused by a condition known as intermittent explosive disorder.
Intermittent explosive disorder (IED) is characterized by repeated episodes of aggressive, violent behavior that are grossly out of proportion to the situation. The National Institute of Mental Health funded a study done in June 2006 that showed intermittent explosive disorder is more common than once thought. Intermittent explosive disorder occurs most often in young men and may affect as many as 7.3 percent of adults in the Unites States.
Individuals with intermittent explosive disorder may attack others and their possessions, causing bodily injury and property damage. Later, they may feel remorse, regret or embarrassment about the aggression.

Signs and Symptoms:
Explosive disruptions, usually lasting 10 to 20 minutes, often result in injuries and the deliberate destruction of property. These episodes may occur in clusters or be separated by weeks or months of nonaggression.

Aggressive episodes may be preceded or accompanied by:
• Tingling
• Tremor
• Palpitations
• Chest tightness
• Head pressure
• Hearing an echo

Causes:
The cause of intermittent explosive disorder appears to be a combination of biological and environmental factors. Lives have been torn apart by this disorder, but medications can help control the aggressive impulses.

Most people with this disorder grew up in families where explosive behavior and verbal and physical abuse were common. Being exposed to this type of violence at an early age makes it more likely for these children to exhibit these same traits as they mature.
There may also be a genetic component, causing this disorder to be passed down from parents to children.

Risk Factors:
People with other mental health problems – such as mood disorder, anxiety disorders and eating disorders – may be more likely to also have intermittent explosive disorder. Substance abuse is another risk factor.
Individuals with narcissistic, obsessive, paranoid or schizoid traits may be especially prone to intermittent explosive disorder. As children, they may have exhibited severe temper tantrums and other behavioral problems such as stealing and fire setting.

Screening and diagnosis:
The diagnosis is based on these criteria:

• Multiple incidents in which the person failed to resist aggressive impulses that resulted in deliberate destruction of property or assault of another person.
• The degree of aggressiveness expressed during the incident is completely out of proportion to the precipitating event.
• The aggressive episodes are not accounted for by another mental disorder, and are not due to the effects of a drug or general medical condition.

Other conditions that must be ruled out before making a diagnosis of intermittent explosive disorder include delirium, dementia, oppositional defiant disorder, antisocial personality disorder, schizophrenia, panic attacks and substance withdrawal or intoxication.
People with intermittent explosive disorder may have an imbalance in the amount of serotonin and testosterone in their brains.

Complications:
This disorder may result in job loss, school suspension, divorce, auto accidents or incarceration.

Treatment:
Many different types of drugs are used to help control intermittent explosive disorder, including: anticonvulsants, anti-anxiety agents in the benzodiazepine family, mood regulators and antidepressants. Group counseling and anger management sessions can also be helpful. Relaxation techniques have been found to be useful in neutralizing anger.

Oppositional Defiant Disorder:

Introduction:
Even the best-behaved children can be difficult and challenging at times. Teens are often moody and argumentative. But if the child or teen has a persistent pattern of tantrums, arguing and angry or disruptive behaviors toward you and other authority figures, he or she may have oppositional defiant disorder (ODD). Emotionally draining for the parents and distressing for the child, oppositional defiant disorder can add fuel to what may already be a stressful and turbulent family life.

Signs and Symptoms:
It may be tough at times to recognize the difference between a strong-willed or emotional child and a child who has oppositional defiant disorder. It is normal for children to exhibit oppositional behaviors at certain stages of their development. However, if the child’s oppositional behaviors are persistent, have lasted at least six months and are clearly disruptive to the family and home or school environment, the issue may be oppositional defiant disorder.
The following behaviors are associated with ODD:

• Negativity
• Defiance
• Disobedience
• Hostility directed towards authority figures.

These behaviors might cause your child to regularly and consistently show these symptoms:

• Frequent temper tantrums
• Argumentativeness with adults
• Refusal to comply with adult requests or rules.
• Blaming others for mistakes or misbehavior
• Acting touchy and easily annoyed
• Anger and resentment
• Spiteful or vindictive behavior
• Aggressiveness toward peers

Oppositional defiant disorder occurs along with other behavioral or mental health problems such as attention-deficit/hyperactivity disorder (ADHD), anxiety or depression. The symptoms of ODD may be hard to distinguish from other behavioral or mental health problems.

Causes:
There is no clear cause underpinning oppositional defiant disorder. Contributing causes may include:

• The child’s inherent temperament
• The family’s response to the child’s style
• A genetic component that when coupled with environmental factors, such as lack of supervision, poor quality daycare, family instability, can increase risk of ODD
• A biochemical or neurological factor
• The child’s perception that he or she is not getting enough of the parent’s time or attention

Risk Factors:
A number of factors play a role in the development of oppositional defiant disorder. Possible risk factors include:

• Having a parent with a mood or substance abuse disorder
• Being abused or neglected
• Harsh or inconsistent discipline
• Lack of supervision
• Poor relationships with one or both parents
• Family instability such as multiple moves, changing schools frequently
• Parents with a history of ADHD, ODD or conduct disorders
• Financial problems in the family
• Peer rejection
• Exposure to violence
• Frequent changes in daycare providers
• Parents with a troubled marriage or are divorced

Screening & Diagnosis:
Doctors usually diagnose oppositional defiant disorder through information provided by parents and teachers. It can be difficult for doctors to sort and exclude other associated disorders – for example, ADHD versus ODD.

Physicians rely on clinical judgment and experience, information gathered from parents and teachers who may fill out questionnaires, and possibly from interviewing the child.

Treatment:
Oppositional defiant disorder is not something a child can overcome on their own, nor can it be solved with medication, herbal supplements, vitamins or special diet. Successful treatment of oppositional defiant disorder requires commitment and follow-through by the parents and others involved in the child’s care. But most important in treatment is for parents to show consistent, unconditional love and acceptance of the child – even during difficult and disruptive situations.

Ideally treatment for oppositional defiant disorder involves the primary care physician and a mental health or child development professional. These health professionals can screen for and treat other mental health problems that may be interfering with oppositional deficit disorder, such as ADHD, anxiety or depression. Successful treatment of the often co-existing conditions will improve the effectiveness of treatment for ODD. In some case, the symptoms of ODD disappear entirely.

A mental health professional can help the parent learn or strengthen specific skills and parenting techniques to help improve the child’s behavior and strengthen the relationship between the parent and child. For example, the parent may learn how to:

• Give effective time-outs
• Avoid power struggles
• Remain calm and unemotional in the face of opposition
• Recognize and praise the child’s good behaviors and positive characteristics.
• Offer acceptable choices to the child, giving him or her certain amount of control.

Although some parent management techniques seem like common sense, learning to use them in the face of opposition is not easy, especially if there are other stressors at home. Learning these skills may require counseling, parenting classes or other forms of education, and consistent practice and patience. At first, the child is not likely to be cooperative or appreciate your changed response to his or her behavior. Expect that there will be set backs and relapses, and be prepared with a plan to manage those times.

Individual counseling may help the child learn to manage his or her anger. Family counseling may help to improve communication and relationships and help family members learn how to work together. Again it is crucial to identify and treat any other disorders that may be affecting the child along with oppositional defiant disorder.

Self-care:
At home, the parent can begin chipping away at problem behaviors by practicing the following:

• Recognize and praise the child’s positive behaviors
• Model the behavior you want the child to have
• Pick your battles
• Set limits and enforce consistent reasonable consequences
• Develop a consistent daily schedule for the child
• Work with your spouse and other members of the household to assure consistent and appropriate discipline procedures
• Assign the child a household chore that is essential and that won’t get done unless the child does it

Coping Skills:
For the parent, counseling can provide an outlet for their own mental health concerns that could interfere with successful treatment of the child’s symptoms. A depressed or anxious parent may disengage form his or her child, and that can trigger or worsen oppositional behaviors.

• Learn ways to calm yourself. Keeping your own cool, models the behavior you want from the child

• Take time for yourself. Develop outside interest, get some exercise and spend some time away from the child to restore your energy.

• Be forgiving. Let go of things that you or the child did in the past. Start each day with a fresh outlook and a clean slate

Mayo Clinic. (2006). Intermittent Explosive Disorder. Retrieved on July 5, 2006 from the World Wide Web: http://www.mayoclinic.com/health/intermitten-explosive -disorder/DS00730

Mayo Clinic. (2006). Oppositional Defiant Disorder. Retrieved on July 5, 2006 from the World Wide Web: http://www.mayoclinic.com/health/oppositional-defiant-disorder/DS00630

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HCPCFC PROGRAM UPDATES and ANNOUNCEMENTS!!!   The HCPCFC nurses stationed at the juvenile courts have been participating in the new DPSS court orientation that is given to parents prior to their detention hearing. It seems to be going very well.

 

Editor: Kristen Thompson, PHN
Contributors: Nicole Boyd, PHN, Assistant Nurse Manager, and Judy Earp, MHA, Director of Public Health Nursing.