T-7 has all of the checkmarks for a Disorder called Oppositional Defiant Disorder, which a high percentage of kids that have ADHD have (which she also has the symptoms of). From Wikipedia:

• A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
  

  Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

  • often loses temper

  • often argues with adults

  • often actively defies or refuses to comply with adults’ requests or rules

  • often deliberately annoys people

  • often blames others for his or her mistakes or misbehavioris often touchy or easily annoyed by othersis often angry and resentful

  • is often spiteful or vindictive

• The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
• The behaviors do not occur exclusively during the course of a Psychotic or Mood disorder. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial personality disorder.

Since mid-January, J-, T-7 and I started a form of therapy known as PCIT. It has been emperically tested that the therapy leads to the improvement in behaviors of difficult children.  It has been a really interesting experience and has led to progress, although honestly we have not seen any behavioral change.  We have only seen change in our ability to navigate her behaviors.  Increasingly, we have been suspecting that T-7 suffers from an attachment disorder, which really needs to be treated with attachment therapy and is a long, slow process.

PCIT is done in a therapy room, with one parent and one child behind a one-way mirror and the therapist on the other side (J- has also been in the room with the therapist). I have a bug in my ear and the therapist is able to direct me in playing with T-7.

Child-directed Segment

PCIT begins with the child-directed play sessions with the parent.  During this part of the treatment, the parent acts as a play therapist. When a “mastery” level is reached byt he parent, then the therapy may move on to the second segment. “Mastery” is reached by eliminating questions and commands from her language and using a high number of praises, exclamations, reflections and descriptions within a certain time period.  The only rules are that the child play with the toys gently and stay in their seat. If they break these rules, the parent ignores them until they do.

This segment is also accompanied by “homework” of child-drected play for 5-10 minutes per night.

This segment does several things. It increases the bond between parent and child and increases a childs self-esteem.  It is actually pretty rare for a parent to spend a full hour letting a child direct everything and get praise and attention. It also (potentially) gives the child a taste of the difference between getting a lot of positive attention and being actively ignored by a parent. When I say “actively ignored”, I mean that I am saying things like “I sure wish T-7 would get in her seat, so I could play with her, she is sooo fun to play with!”

We were so motivated to see behavioral change, that J- and I joked that I would be the first person ever to pass out of this segment on the very first try. Well, I was close the first time, but the equipment was broken. The second time, I wasn’t quite warmed up and T-7 was being a bit difficult. The third time was a charm and we were able to sail into the Parent-Directed.

Parent-Directed Segment

We wondered if T-7’s behavior would really be triggered in this artificial context.  Our concerns were put to rest during the very first “practice” session, when I played with her for 15 minutes. When I announced that it was cleanup time, she threw her body over the toys on the table and hissed at me.  When I calmly restated it and started taking the toys away, she started screaming “No, no, no, no!” And fell out of her chair.

The rest of the sessions consisted of bringing out blocks, crayons, legos or cars.  In addition to the regular praise, reflection and descriptions, I would give her commands of things to do with the toys. If she could not mind, she would be asked to take a time out in a chair for 3 minutes. If she remained in the chair and was quiet during the last 30 seconds of the period, the time out would end. If not, she would get another time out.

The main thing that I have gotten out of this part is that I am now very careful to use clear commands. I saw T-7 get really upset one time when she was confused about what I wanted her to do and she made the wrong choice.  I realized that most of the time when we have problems with her, she has divided priorities. Usually, she thinks that what she is doing is more important than what we ask her to do.  Well, it can be a bit like dawdling. The problem is that it is never a few minutes. If we do not demand immediate compliance (and escalate it), then she spirals out of control.   Occasionally, she will feel that she is still on task with something else.  So, when I use clear commands, there is absolutely no doubt what I am asking for and when it should be done.

Until our last session, we didn’t get much of a reaction from her. She did earn 1 time out, which it took 2 time-outs to complete, but that was a huge accomplishment for her.  She would get bored and would complain.  She also had an almost magical sense of pushing limits. She would always protest long enough so that she would be just about the get a time out, but then comply at the last moment.

We considered starting to do the therapy at home, that it was time to start integrating it into our everyday life, where we were still often relying on containment and restraint.  Then I noticed that most of the time when she wasn’t complying at home, it was because she was doing something with her dolls (or sometimes her other toys). My feeling was that she didn’t care enough about the toys that we were using.  Yah, she wanted control, but not enough to take a time out and stop playing. We decided to up the ante and Jeff and I brought her Barbies to the session. She loves everything about dolls, but especially doing Barbie hair.

T-7 was in a particularly difficult mood that day. We had trouble getting her into the building, we had had trouble getting her into the car earlier in the day. Well, it only got worse.  In the beginning of the session, we played with blocks and trucks. I did have to threaten time outs a few times, but she complied.  Then, I made the call for the doll delivery. That exploded the session.

It is almost a relief to be screamed at, grabbed and hit in front of a therapist. We can describe her behavior till were blue, but not many people actually see it and how awful it is.  It is validating that the therapist is going to have to call in her supervisor to help. We have read a lot of freaking therapy books, but kids with attachment problems do not really respond to most things and none of the solutions work on an immediate or even short-term scale. Even the behavioral experts are at a loss with these kids.

It is even better that it was recorded on video tape. We feel that her behavior has been minimized by social workers (especially her county social worker) and we now have tangible proof that we are not simply bad parents or dealing with her in the wrong way.  And we can’t wait for all of them to watch it.