Cognitive Behavioral Therapy and Client Centered Therapy for Children and Adolescents with Oppositional Defiant Disorder and Conduct Disorder
Cognitive Behavioral Therapy and Client Centered Therapy for
Children and Adolescents with Conduct Disorder and Oppositional Defiant Disorder
Children and adolescents are curious minded individuals for the most part. They engage in various activities with an uninhibited and innocent level of insight. Their level of logic is surprising, and at the same time can be a refreshing change. Now suppose that the amusing behavior and logic were to take a sudden turn. Imagine a child who constantly challenged authority from all angles and exhibited extreme fits of rage and anger. Imagine a child who only needed two hours of sleep a night and could run throughout the entire day at full-throttle. What would be the initial impression and reaction of the onlooker
Conduct Disorder
Children and adolescents suffering from Conduct Disorder (CD) often display the symptoms mentioned. Parents, teachers, and family frequently appear to be exhausted after having spent only moments with the child. It is tantamount that one understands that the child or adolescent has absolutely no control over the afflicting mental disorder. Their behavior is unintentional. At this juncture, the child or adolescent believes him or herself to be as normal as everyone else.
Clinicians have collectively termed CD as a group of behavioral and emotional problems in children and adolescents displayed through socially unacceptable behavior (American Academy of child and Adolescent Psychiatry, 2004 Burke, Loeber, Birmaher, 2002). Children and adolescents diagnosed with CD are known for their illegal temperaments. They have been reported to be overly aggressive and physically threatening towards animals and people alike. They are destructive of property of their own and that which belongs to others. They will steal without reason and lie at will. It should also be noted that these behaviors are correctable and manageable if the proper treatment is facilitated.
The origin of this childhood mental disorder has been related to several contributing factors. The first instance pertains to possible brain damage or a neurological impairment. Members of the medical community contend that the neurological damage could be attributed to reduced or lack of adequate oxygen during labor and childbirth. Neurological damage could also likely be substantiated by the child being a victim of child abuse whereby he or she may have experienced blows to or about the head. Emotional trauma and genetics are among other sustaining factors believed to be at the epicenter of the disorder. Children and adolescents who have parents that suffer from mental illness are more apt to develop a mental disorder before completing puberty.
The prognosis for a child or adolescent perplexed by CD is a positive one. Behavioral therapy coupled with medication seems to be the most effective means for managing CD. For the purpose of this paper, cognitive behavioral therapy and client centered therapy will be closely examined for accuracy in both an individual and a group clinical setting (Harty, Miller, Newcorn, Halperin, 2008). As a whole, the treatment for CD is individualized. The therapist will conduct important diagnostic tests in order to find out the severity and true existence of the Conduct Disorder. Once a decision has been made, the therapist will put together a treatment plan in order to get the child or adolescent back on a healthier path of living.
Oppositional Defiant Disorder
Oppositional Defiant Disorder (ODD) is very similar characteristically to CD. Both disorders appear in childhood and adolescence, but they are usually seen in conjunction with other mental disorders such as depression and Attention Deficit Hyperactivity Disorder (ADHD). ODD is surmised by uncooperative and hostile behavior absent any physical or emotional trigger (Skoulos Tyron, 2007 Oatis, 2009). Children and adolescents are known to throw acute temper tantrums, argue, have a lack of respect for authority in any form, act in deliberate defiance, antagonize others, refuse to assume responsibility for their actions, and have a general hateful and spiteful attitude (American Academy of Child and Adolescent Psychiatry, 2009). This behavior significantly interferes with the child or adolescents ability to function in or out of the home. Psychologists agree that children and adolescents diagnosed with ODD have a higher rate of developing Antisocial Personality Disorder or depression as an adult.
The origin and nature is believed to be of a biological, psychological, or social factor. The biological conclusions are drawn from a family history of mental illness or in the form of a chemical imbalance. Despite the chemical imperfection, medication is not a productive means of treatment in ODD. The psychological aspect and how it contributes to the existence of ODD relies heavily on a child or adolescents personal life up to the present. The child or adolescent is believed to have been a victim of child abuse or neglect. They could be the product of an undiagnosed co-morbid condition that excels ODD behavior or a number of other psychological reasons, however the diagnosing psychiatrist will make the final determination. There are a number of social factors that are thought to be the origin of ODD as well. Peer hazing or taunting, low self-esteem, lack of solid friendships, or lack of a structured living environment at home and elsewhere are believed to have a direct effect on the development of ODD in children and adolescents. ODD is one of the most commonly diagnosed mental disorders among children and adolescents.
The methods of treatment for ODD are limited at best (Kelsberg St. Anna, 2006). Children and adolescents with ODD do not generally respond well to the administration of any drug. Therapy, either cognitive behavioral therapy or client centered therapy, is the best alternative. Parent training is another technique endorsed for treating ODD. Parents attend a training seminar that teaches redirection and positive reinforcement. The how-to process of parent training enables the parent to implement the techniques therapeutically at home. Family therapy is sometimes used depending on the demands of the child or adolescents responsiveness to other methods of therapy.
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) is a form of therapy that attempts to re-program how one interprets a situation. Actions and reactions are predetermined by the cognitive thought processes of the mind. In children and adolescents, there are five basic concepts of thinking. The focuses are interpersonal and environmental, physiological, emotionally functioning, behavior, and cognition (Durlak, Fuhrman, Lampman, 1991 Friedberg McClure, 2002). The interpersonal and environmental concept focuses on the client being able to differentiate between a feeling and a thought. The physiological focuses on becoming aware of thoughts that produce a negative influence on feelings.
The emotionally functioning concept learns and understands the occurrence of automatic thoughts. In the behavioral concept, one learns to analyze the automatic thoughts for accuracy and bias. Finally, the cognition concept develops the skill needed to control and correct any bias energy associated with independent thought (ABCT, 2010). Children and adolescents with CD or ODD benefit from CBT because the issues of emotional rejection, secondary physical symptoms, and the illogical thinking process are addressed.
In Conduct Disorder
Children and adolescents with CD are frequently treated with CBT. Cognitive behavioral therapy planning for children and adolescents involves the evaluation of logical and analytical structures of thought as they relate to the clients social perspective taking abilities (Kinney, 1991). This is especially important in the individual therapy setting. Therapists working with children and adolescents with CD tend to take on a teaching role when using CBT (Grohol, 2004). This direct approach in counseling is validated through progress.
The general idea of Cognitive Behavioral Therapy in children and adolescents is based on the ideas of modeling and re-enforcement. A productive social learning environment can be achieved through role playing, modeling, Rational Emotive Therapy (RET), and the use of other reinforcement strategies (Grohol, 2004). These approaches are based conclusively on the exact problems associated with CD in relation to how the client presents. CBT for children and adolescents with CD is estimated to be short-term, three to nine months in duration, and include 10-35 sessions in total. Single sessions do not produce a positive result (Journal of American Academy of Child and Adolescent Psychiatry, 1997).
Some forms of CBT are found in places that many would not consider. Young children can benefit from CBT in Head Start programs readily available in most communities. These pre-school academic models are designed to aid in the intellectual, academic, and social dynamic of the child while in a playful and fun setting. Visually, the head start program is a group setting, but the individual client is placed into the program for the educational, social function, and modeling benefits. Consequently, older children and adolescents are often placed into a vocational training setting as a means of raising self-esteem, modeling, improving the educational abilities of the adolescent, and developing a positive social skill and function (Kinney, 1991 American Academy of Children and Adolescent Psychiatry, 1997).
Cognitive Behavioral Therapy has been found to be more beneficial when administered in the child or adolescents natural environment. Home based CBT is a plus if available to the client. Age is not a variable in CBT since there are many approaches that can be utilized and administered. Younger children respond well to toy play, puppet play, games, drawing, and crafts (Friedberg McClure, 2002). Adolescents find a useful connection in CBT through the use of movies, television, and music as these activities incite verbal communication during therapy sessions. Constant focus must be centered on the positive.
The identification of thoughts and their correlation to feelings plays an important role in CBT. The use of a facial expression chart is often introduced into therapy sessions with young children. Communication barriers inhibit young children from verbally expressing their feelings. Facial expression charts allow the child an alternative form of communicating their exact feelings (Johnson, 2010). The uses of picture books permit the same emotional components to be factored into the session. Older children and adolescents are able to communicate their feelings without hesitation, including those of a negative connotation.
Some clients, both children and adolescents, are intent on remaining silent and unresponsive. This evasive uncooperativeness can be viewed as a passive aggressive behavior aimed at retaliating against those thought to be responsible for mandating the therapy. The therapist must then divert to other ways of communicating with the client. This is a good opportunity for the therapist to begin working with the client on connecting the physical with the sensations of the emotional. Questions can be proposed in relation to school or family in relation to physical areas such as the stomach or the head. A classic example question that a therapist could ask would be, when you found out you were coming here today, how did that make your body feel This open question allows the adolescent to answer honestly. It opens the lines of communication for other questions and conversation. Later questions pertaining to immediate thought and ideas associated with the clients thought process can be explored. At this point, the client would begin focusing on identifiable thoughts and connecting them with associated feelings.
In Oppositional Defiant Disorder
Therapy is the key treatment in ODD since it is relatively unaffected by any medication (American Academy of child and Adolescent Psychiatry, 2009 American Psychiatric Association, 1994). CBT in children and adolescents with ODD teaches them how to view situations differently than they had. The time-out system is a form of CBT. The brief but isolating period gives the young child an opportunity to think about how they behaved in an unacceptable manner. When the period of isolation is over, the child is then asked why he or she was subjected to a time-out. This question presents the child with the opportunity to show that they have learned a lesson concerning their behavior. The question also signifies that the behavior redirection session is over for the moment.
Therapy is a given for children and adolescents with ODD. Cognitive Behavioral therapy should be initiated in all aspects of the clients life including the academic setting. CBT techniques can be put into practice on the home front as well through specialized parental training. A ready to use routine is a plus for a child or adolescent with ODD. Once a regular routine for treatment has been devised, the client will over time begin to experience less stress and anxiety. Life stressors are major triggers associated with ODD. The family, the school, and the mental health practitioner should form an open line of communication to provide a more probable outcome for the client.
The school system can provide a Cognitive Behavioral therapy based environment to the child or adolescent through the special education program. Teachers in the special education program are specially trained to handle not only the educational needs of the student, but the emotional needs as well. Mental health professionals need make their presence available for any Individualized Educational Planning (IEP) for children and adolescents who are actively in therapy. This would ensure that the school can devise a plan that would coincide with the current treatment course of action already in place. Parents of the child should take an active role in both planning processes as they will ultimately be spending the most time with the child or adolescent.
Many of the same therapeutic techniques are incorporated into the CBT for a child or adolescent with ODD as is in a child or adolescent with CD. Sessions usually average from 10-15 depending on the progress of the client. ODD can hinder a client from fully participating in therapy at times due to outbursts of anger, disruptive behavior, and the constant need to refocus the client. Role playing, play therapy, and one-on-one individual CBT have proven to be a successful treatment plan in young children. Sometimes, older children and adolescents fare better when the CBT is started in an inpatient hospital setting. The decisions, the how and when to begin CBT, belong to the treating mental health professional. The severity of ODD in the client has a major impact on the intensity of the treatment as well. It is necessary to stabilize the patient before enveloping them into a therapeutic process. One time sessions do not provide stabilization, nor are they effective forms of treatment for ODD (Kelsberg St. Anna, 2006)
In a Group
CBT to treat CD or ODD in a group setting is very similar to that of treating just the individual client. School and vocational locations do provide a group therapy atmosphere and encourage group participation. Group CBT promotes increased feedback from its clients. The modeling approach gives children and adolescents a chance to see firsthand how others, within the same age perimeter, handle and cope with specific situations (PsychCentral, 2001).
Coping strategies and social skills are two benefits of group CBT. The following is an example of how these lessons are taught and learned in a group CBT session. The lead therapist treating a group of ten adolescents with CD or ODD decides to take the group on a bowling outing as part of the group therapy session in action. The parents of the adolescents agree to go as well as this is a therapeutic outing. While out bowling, little Johnny becomes very agitated and angry when he sees that he is the only one who has yet to bowl a strike. His anger steadily increases and he erupts by throwing his bowling ball into the floor. In doing so, he smashes his own foot. The other adolescents in the group stand in awe of little Johnnys outburst. The therapist immediately goes over to little Johnny and asks him how his foot is. Johnny does not answer. The therapist then asks him how his body felt when he threw the ball. Johnny states that his body felt lighter, but his foot is pounding. The therapist then asks Johnny how his body felt before he threw the bowling ball onto his foot. Johnny states that he felt hot and that his body felt really tight. The therapist explains to Johnny and the rest of the group that what Johnny was feeling was called anxiety. She further explains that everyone feels a little anxious whenever they play a game because it is a competition. She reiterates the fact that bowling is just a game and nothing more, but that what Johnny was feeling was very real and was because of the game.
The other adolescents observed the conversation between the therapist and Johnny. In a group therapy setting, there sometimes exist live examples to learn from. This instance also gave way for improved social skills and communication. It allowed for a positive interaction between the therapist and the other clients as well. Group therapy generally does not have more than twelve participants at any given time. If there are more than twelve, then the clients can be too easily distracted and the group session becomes a sort of disorganized chaos. In the matter of Cognitive Behavioral group therapy, less is more, and that is a good thing for all seeking treatment.
Client Centered Therapy
Client Centered Therapy (CCT) is a behavioral therapy developed by Carl Rogers in the 1930s (Rogers, 1939). This approach to counseling places the responsibility of treatment onto the client. Some therapists see client centered therapy as a way to increase the clients level of insight through self-understanding. Client centered therapy is based on three fundamental basics of success. These criteria are congruence, unconditional positive regard, and empathy (jrank, 2010). Since no child or adolescent behavior or attitude is the same every day, it is crucial that the treating therapist be flexible in their own thinking and thoughts in order to recognize the emotional needs of the client.
Congruence depicts a therapists ability to be personable and equal to the client on a human level of existence. Therapists who come off as being better-than or condescending and judgmental will assuredly fail the client. In CCT, the client is looking for acceptance and reassurance. These needs can be met by the therapist through unconditional positive regard. The therapist can develop a solid therapeutic relationship with the client by merely listening without interrupting or interjecting opinions of judgment. Finally, empathy must be asserted in CCT I order to gain trust from the client (Green, 1996). A client will not cooperate, open-up, or express any therapeutic effort if they feel misunderstood. Empathy is a major portion of CCT and relies solely on the treating therapist. Much of the work in CCT is centered to the attitude of the therapist. CCT for children and adolescents provides a safe and effective solution to many behavioral problems through a therapist who acts like a human being and not a robot (Psychology, 2010).
In Conduct Disorder
Client centered therapy gives children and adolescents the freedom to discuss concerns and relevant matters with the therapist. Since the CCT approach puts the emphasis on the client, the therapist generally takes a passive role in therapy. In CD, the therapist initiates some focus on issues of impulse control, problem solving, and anger management (Tryon, 1999). This is achieved by using a four step process of understanding. The therapist begins by using the modeling technique and proceeds by adding rehearsal and role playing. The final outcome is delivered when the child or adolescent develops an internal voice used for self-evaluation (Kazdin, 1987).
There are various methods of client centered therapy used in treating conduct disorder. The first is Parent Management Training (PMT). Parents or caregivers of the child or adolescent are taught by the therapist, or in a group class, how to effectively set limits, redirect the child, and use positive behavioral reinforcement. Research has shown this to be a very important and productive part of treating CD (Teusch, Bohme, Finke, Gastpar, 2001). The PMT is often used in conjunction with family therapy (Sanders Dadds, 1993). Family therapy provides outlets for all family members, and not just the child or adolescent with CD. Sibling issues and parental power struggle issues can be addressed and resolved within this therapeutic setting. Family therapy is used to reinforce the family dynamic through CCT (Searight Rothneck, 2001).
Age is an important variable to be considered in CCT. Children and adolescents diagnosed with CD before age ten seem to do more poorly from CCT than do those who were diagnosed with CD after the age of ten (Dishlon Andrewa, 1995 Rogers, 1939). It can be asserted that children and adolescents under the age of ten are still more formularizing in their thinking. Their behavior and thought process is still in the abstract stage. This allows the child to be more easily manipulated and thought patterns can be redirected (Cantwell Baker, 1988 Kaplan, 2008). Children and adolescents older than the age of ten seem far more rigid and stubborn than younger children, but in a therapeutic setting, the children are more open to suggestion and change. It is important that the therapist include self-reflection in the CCT as a way to help the client understand their maladaptive behaviors.
Peer relationships are a form of CCT in a school based setting (Dulcan Weiner, 2006). Social skills and interactions of clients diagnosed with CD can be closely monitored and modified if necessary. School academic clubs or sports organizations provide a good therapeutic CCT environment for the adolescent or child. The primary purpose is helping the child or adolescent to use problem solving skills in every situation as a way to control the impulses that trigger anger and physical acts of violence. Client centered therapy is prosocial and usually consists of twelve sessions (Rutter Taylor, 1994).
In Oppositional Defiant Disorder
Early intervention and CCT treatment for children and adolescents with ODD holds much promise. The goals of CCT in treating clients diagnosed with ODD are parallel with the treatments for CD. Therapy focuses on self-esteem issues and self-understanding. These individual focuses enable the client to be more open to the therapeutic process, relieve insecurities, decrease defensive cognition, and eliminate any residual guilt (Ellis, Abrams, Abrams, 2009 Rogers, 1951). In young children, ages 3-11 years, play therapy is very effective in an ODD diagnosis. Essentially, treatment is short-term, 12-25 sessions (Barkoukis, Reiss, Dombeck, 2008). Young children are able to articulate their feelings by playing games or interacting with toys. Therapists watch carefully for behaviors that indicate problem areas. In turn, these areas are addressed and the focus turns to the client. Questions can be proposed in reference to, what do you think should be done here Or what would you like to do (Martin Pear, 1999). Children seem to be more receptive to the questions when they feel that they are in control.
Parental Management Training (PMT) is also used for ODD clients in CCT. Parents have reported a high success rate and increasing positive behavior after having PMT (Casey Berman, 1985 Forehand Long, 1996). Family therapy is also integrated into the treatment plan. CCT is included in special education programs in the public school sector. Guidance counselors and special education teachers are able to monitor the child and adolescents progress in an academic and social environment. The social skills perspective is also examined through the child or adolescents peer group (Sungerg, Weinberger, Taplin, 2001).
In a Group
Client centered therapy with a group consists of a group of 3-5 children or adolescents. Desensitation exercises are introduced and used for eliminating stress (Brown Prout, 2007). There is much organic interaction between the children and adolescents. The therapist opens the floor for discussion or delivers a topic for discussion to the group. Dialogue and talk therapy help the client to develop and utilize problem solving skills and participate in a social perspective (Rogers, 1942 Shirk Karver, 2008). This can be performed through organized athletics, community groups, body and girl scouts, and church group activities. Family therapy is also associated with group therapy, and is used to treat both CD and ODD in a CCT environment. The prognosis for children and adolescents is promising. Children and adolescents seem to respond well to CCT.
Analysis
Rutter and Taylor reported in 1994 that 5 of children in the United States have Conduct Disorder, and 20 of children and adolescents have Oppositional Defiant Disorder. The first child to receive psychotherapy was in 1905, and the therapy was administered by Sigmund Freud (Reinecke, Dattilio, Freeman, 2006). Children and adolescents go through phases of oppositional behavior and conduct abnormalities as they grow. This is considered to be a normal part of childhood development. When the disruptive behaviors linger and persist, it is necessary to have a psychologist perform an assessment to determine if there is a mental disorder (American Academy of Child and Adolescent Psychiatry, 2007 Reich, 2000).
In a study performed by Shirk and Karver, it was determined that CCT and CBT produced a modest outcome for children and adolescents diagnosed with disruptive behaviors like CD and ODD (Shirk Karver, 2008). The study made several findings concerning psychotherapy in children and adolescents. Children displayed a poorer response to CBT where CD and ODD were co morbid. Hostility, as associated with CD and ODD, prevented the child from forming relationships with other children (Gresham, 1986).
The Helsinki Psychotherapy Study monitored patients for twelve months after the onset of therapy. It was determined that 46.86 of patients dropped out of psychotherapy before completion (Wierzbicki Pekanik, 1993). Throughout their study, they discovered that different therapies required a different number of sessions. Solution focused therapy required a maximum of twelve session, and short-term psychotherapy required twenty sessions over a 5.7 month period (Knekt Lindfors, 2004). Children and adolescents being treated for ODD and CD usually participate in CBT and CCT for periods of less than twenty sessions. Solution focused therapy is very similar to CBT and CCT in that they identify the problem and work to find a solution. It focuses on positive feedback and home assignments as well. There is still much research needed in order to truly determine the effectiveness of CBT and CCT for conditions of CD and ODD in adolescents and children (Maxwell Delaney, 2003).
Discussion
There are still concerns where CD and ODD are concerned in reference to the possibility of co-morbid conditions. ODD and CD are commonly found to co-exist with ADHD, depression, and anxiety. In these other conditions, ODD is merely a coping mechanism to the primary condition. Over half of the children and adolescents with ODD also have ADHD (Keisberg St. Anna, 2006). Some clinicians have questioned whether CD and ODD are simply pre-ambles to future more serious mental disorders. There is a correlation between CD and antisocial personality disorder. Some would argue that intervention was not implemented soon enough therefore the original condition had more time to fester and evolve into a more damning condition.
Not every member of the mental health community is in agreement with regard to the conditions of CD and ODD, nor is everyone in agreement as to how the conditions should be treated. It has been suggested that an inpatient hospitalization would be more a more productive way to evaluate a child for Conduct Disorder or Oppositional Defiant Disorder. This is argued from the other side in that a child will naturally produce adverse reactions when taken out of their natural environment. The initial trauma of being separated from their parents or caregivers can actually cause more damage than good.
If mental health intervention is delayed for too long, the likelihood of the child or adolescent becoming involved with the legal system is greater. Some juvenile court systems are ignorant to how mental conditions can affect ones behavior. Instead of referring the children and adolescents for mandated counseling and a psychological assessment, many judges view the child as encourageable or as a bad seed who needs to be taught a lesson. These children and adolescents find themselves in shock incarceration, boot camps, and solitary confinements within a juvenile detention facility. While there are licensed therapists and psychologists on staff at these facilities, there are less empathetic to the emotional needs and conditions of the child. They are often overrun with heavy caseloads and have little time to even acknowledge the child as an inmate. This behavior is counterproductive when one has a mental disorder.
It must be noted that misery loves company and that monkey-see-monkey-do. Some behaviors exhibited in children are mimicked of other children. If a child is acting out and crying, for instance in a daycare setting, that somehow triggers every child in the room to begin whining and crying as well. It is like a domino effect. The true behavior patterns of a child must be examined closely against any flaw of assumed behavior. Psychological testing and assessments can assert underlying behaviors that must be addressed immediately. Not every child is in crisis, but when a childs behavior disrupts their ability to function in and out of the home, it is necessary to give the matter top priority.
Insofar as communications are concerned, it is ultimately up to the parents or caregivers to sign the necessary releases so that therapists, schools, physicians, and other authorities over the child and adolescent can keep one another informed or report any concerns. This is a vital part of the treatment process, but it often goes overlooked. A teacher should be able to talk to the parent and the attending physician if they feel that a medication may be too strong or too weak. In turn, a physician should be afforded the opportunity to speak with a teacher to make them aware of any medication changes or specific behaviors to keep an eye out for. The only way to effectively treat a child or adolescent with CD or ODD is through honesty, openness, and a willingness to aid the child in any way possible.
Conclusion
Conduct Disorder can be treated with medications in conjunction with therapy however ODD cannot be treated with medications unless there is a diagnosis of a co-morbid condition. Children and adolescents present with many symptoms which require psychological assessment in order to determine the best treatment route. Clinicians believe that CBT and CCT are the most effective forms of treatment for disruptive behaviors. Parents concur to therapy as they also participate in a PMT in order to help their child from the home setting. Special education teachers and guidance counselors are trained to aid children and adolescents experiencing emotional battles. While treatment is relatively short-term, it can seem to drag on forever when dealing with a child who is hostile, violent, disruptive, disrespectful, and sometimes even criminal. Parents must educate themselves as to what is within the normal confines of childhood development and what is out of the ordinary. Parents are the first step to a child receiving the proper diagnosis and treatment for any emotional or mental condition.
Therapists must conduct their sessions with the upmost integrity towards the patient. Empathy and understanding are key factors in treating children and adolescents. Trust can be established more easily between client and therapist if the therapist is personable and relaxed. Therapists take on the role as teachers when working with a client in a CBT setting. A good therapist must be able to be transverse and be able to adapt to the need of the client.
Clients, children and adolescents, who have CD and ODD, are still human beings. They have no idea that there is even anything wrong with them. They function within their own reality of normal. Some symptoms of CD and ODD make therapy challenging for both the therapist and the client. Hostility and anger issues usually present with the most problems. All in all, the prognosis for children and adolescents with CD and ODD looks good, but it will probably get a whole lot worse before it gets any better.
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