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Ask the Mental Health Expert Archives 2001-2004

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Q. I am the 504 Coordinator for an alternative high school. One of our new students has been diagnosed with intermittent explosive (IED) and oppositional defiance disorders (ODD). I need information about the conditions as well as how to best avert and deal with these behaviors in the classroom. I have found some useful information on the Internet about ODD, but did not find much other than a definition for IED. Any information that you can send or direct me to would be greatly appreciated.

A. Both these conditions--ODD and IED--are quite controversial. Some child psychiatrists consider these as garbage can diagnoses--meaning that kids get thrown into these categories when clinicians fail to uncover the real underlying diagnosis.

For example, ODD or IED may be diagnosed in children who actually have a bipolar disorder. Kids with bipolar disorder may act up, misbehave, or be downright aggressive and violent if they are in an irritable manic period. Intermittent Explosive Disorder is one of the so-called Impulse-Control Disorders, Not Elsewhere Classified in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.)

IED is characterized "?by discrete episodes of failure to resist aggressive impulses resulting in serious assaults or destruction of property?" (DSM-IV p. 609). The degree of aggressiveness is "?grossly out of proportion to any provocation or precipitating psychological stressor". Very often, individuals with IED describe a build-up of tension before the aggressive behavior, followed by a sense of relief after the explosive act, which in turn may be followed by a period of guilt or remorse.

The diagnosis of IED is NOT made if the behavior in question is better explained by another psychiatric (or medical) condition, such as a manic episode, brain trauma, etc. IED probably represents a collection of different conditions with different underlying causes.

For example, some individuals with IED may show nonspecific abnormalities on their EEG (electroencephalogram or brain wave recording), whereas others do not. Some children with a diagnosis of IED may actually have undiagnosed or concomitant bipolar disorder (see, for example, McElroy et al, Are impulse-control disorders related to bipolar disorder? Compr Psychiatry 1996 Jul-Aug;37(4):229-40). So--it's absolutely critical that the new student you describe gets a thorough neuropsychiatric evaluation!

Medication may be both helpful and necessary to manage some cases of IED. However, behavioral strategies may be useful in milder cases. You can get some tips on behavioral management techniques at the website http://www.teachervision. For example, the following advice is given to deal with the argumentative student:
1. Do not confront the student in a group situation.
2. Do not use an accusatory tone upon approaching the student.
3. Evaluate the situation that led to the confrontation.
4. Do not back the student into a corner. Leave room for options.
5. Do not make threats that cannot be carried out.
6. Allow your emotions to cool before approaching the student.
7. Maintain the appearance of control at all times. Use a clear, firm voice.
8. Give the child an opportunity to speak his/her piece.
9. Allow for role-playing, doing role reversal.
10. Try to explore and discover what led to the confrontation. Avoid repeating these circumstances.
11. If you made an error, admit it!

Clearly, these are very general tips and may not apply to the student in question. I would therefore suggest working closely with the school psychologist and/or the student's own psychiatrist in formulating your management strategy.

January 2004

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