Disruptive Behavior Disorders:

1. Introduction to the disruptive behavior disorders:

  • A disorder that causes behavior that is significantly disturbing to others (such as aggressive, impulsive, argumentative behaviors, etc.).
  • The disruptive behavior disorders are abnormal behaviors that are expressed in many different forms. Such behaviors are usually portrayed as inappropriate among most individuals in a society. They are also called Behavioral Disorders. These behaviors also violate the social norms of others and especially towards their siblings. People "break the rules" a little all the time and children also, and especially the rules that they believe are not as important. Over time, children tend to mature and outgrow these disruptive behaviors. When they do not, psychological evaluation is usually advised as this behavior can lead to other more serious disorders (antisocial personality disorder, etc). Several things can lead up to the disorder, including both a biological and environmental basis. Initially, there was much debate over whether or not oppositional defiant disorder (ODD) and conduct disorder (CD) should be classified as one disorder, with ODD being a milder precursor to CD. However, it was found that 75% of children with ODD do not develop CD. Although these are found to be separate disorders, they do share many common features such as defiance, aggression, and rule breaking behaviors.
  • There are three main Disruptive Behavior Disorders:
    • Oppositional Defiant Disorder
    • Conduct Disorder
    • Attention Deficit Hyperactive Disorder (ADHD)


Parents:

  • Parents need an arsenal of coping strategies to reduce the behavioral problems at home. The first step is effective diagnosis and treatment by a practioner with experience in mental disorders of childhood. Nearly all of the behaviors associated with the Disruptive Behavior Disorders (DBD) may be seen in normal children from time to time. The Disruptive Behavior Disorder (DBD) diagnosis is made when the frequency and persistence of these symptoms result in clinical impairment in social, academic or occupational functioning. Ongoing supervision by a competent mental health practitioner is crucial because the disruptive behavior disorders are frequently accompanied by other disorders such as ADHD, Anxiety, and Mood Disorders.
  • Children with DBD's need a higher level of supervision than other children of the same age. However, supervision does not always have to be by the parent. In fact, because defiant behavior is often directed primarily at parents and teachers, parents may find that alternative caregivers, such as competent babysitters or aides, are able to develop good relationships with the child that provide social learning for the child and valuable respite for parents.
  • Respite and parent support are important because parents need to be in control of their own emotions during difficult episodes with the child. These kids enjoy making you mad, and they are good at it. Parents need to maintain an emotionally neutral stance when giving instructions or consequences to the disruptive child. This skill does not come naturally and must be practiced and perfected over time. If parents don't learn to control their own emotions when disciplining the child, the result is often violence and escalation of the disorder.
  • Find ways to maintain a positive relationship with your child. Pay attention to his good qualities and find joy in the moments of closeness. We naturally avoid people who cause us anxiety and are angered when they hurt us. But, we love our children and that drives us forward to seek healing for them and for us. You need an outlet for your own feelings, so seek out support to help you cope. Many parents also find that they need support to maintain a healthy, supportive marriage in difficult situations.
  • Get a plan and stick with it. Learn all you can about how to effectively manage your child's behavior; find what works for you; and then use those strategies in a consistent and structured way. Routines and clear expectations for behavior benefit all children. They are vital to the healthy development of the disruptive child.
  • Resources for common behavioral problems associated with the diagnosis of Disruptive Behavior Disorder and strategies for parents:
  • Instead of feeling anger, frustrated, and becoming overwhelmed when children display disruptive behavior, as a parent, role models, and educators we need to be empathetic and feel compassion and love for these children. We love those children, just not their disruptive behaviors. One main reasons children are disruptive, is due to a lack of boundaries and goals not being set clearly at an early stage of life, this lack can lead to disruptive behavior in and outside the home. We need to be specific and concrete on what needs to take place in the home, outside the home, in school, ect. We must model what success and appropriate behaviors look like and show children how to exhibit these positive behaviors.
  • When talking to your children, let them know exactly what and how good behavior needs to be implemented. Remember to be specific; don't just say "be good today" but state "be good today by not disrupting the classroom and listening to your teacher." Talk about these goals and objectives each day with your child, and if inappropriate behavior follows, consequences need to immediately be followed through as well. Reward immediately and efficiently when your child is effective and responsive. Use eye contact when giving requests, and have your child repeat back to you what you have said in order to ensure that he really understands what needs to be accomplished. Make realistic and achievable goals for your children, and let them know the consequences beforehand to reinforce good behavior. This allows the child to stop and think about actions before reacting. By setting expectations too high for your child, you are setting them up for failure, and they respond by feeling overwhelmed and frustrated. 
  • It is also very important to remember not to look at your child's "C" grade, but to look at the progress from a failing class. Successful treatment does not happen overnight. So many parents want results immediately and get anxious, which causes the child to feel "anxious." This system does not work. This progress needs to be slow but steady. If a child acts up less each week, that is an example of slow but successful and steady progress, and children need to be acknowledged and rewarded. Gauge success by your own child's standards, not by what is considered "the norm" or someone else's standards. Focus on your child, we will be not be set up for failure if we are not constantly comparing our children or ourselves to others. Remember that each child is special, unique, and responds differently.
  • I highly recommend star charts or success charts to gauge students' progress in specific behavior, but be sure to include your child in this process. It is important the child sees progress daily to focus on the behaviors and positive feedback and be part of this process. Reward systems work well for students of all ages, not just the younger ones. Success charts benefit the child and get the whole family involved. Older children can also use privileges such as pagers, driving the car, cell-phone usage, etc. The family must be supportive and consistent in reinforcing positive responses and outcomes when they occur. Remember: it is essential to set specific, measurable, achievable, realistic, and time efficient goals. This will make a big difference to help disruptive behaviors become deserving behaviors ! This is what we want!
  • We must avoid being reactive towards this resistant behavior from our children. Show your child who's in control by demonstrating self-control and restraint. Always stay calm, controlled, and collected when your child acts up. Remember: act rational to create rational behavior and responses from your child. Time-outs are highly effective for younger children, and a good formula to use is one minute per one year of age, e.g. 6 minutes for a sixyear old. The child needs to have time out to understand what was done wrong, and what he can do better next time, and should resolve the issue with an apology.

Epidemiology for Disruptive Disorders:

  • Conduct problems are one of the most frequent reasons for referral to child and adolescent treatment services. Prevalence rates are estimated to be 2-5%.
  • These problems are more often diagnosed in boys than in girls: 3-4:1 ratio, perhaps because of the emphasis on male expressions of aggression.
  • Contextual factors (poverty, high-crime neighborhoods) increase conduct problems.
  • ODD is often a precursor of CD, although the child cannot receive both diagnoses.
  • Average onset for ODD: six years old; for CD: nine years old.
  • Most children (75% in one study) do not progress from ODD to CDl
  • Co-occurring disorders include ADHD (35-70%); ADHD often comes first.
  • Profile of children with disruptive disorders includes peer rejection, lower school achievement, verbal/language deficits, deficits in executive functions.
  • Co-occurring disorders also include anxiety disorders (19-53%) and depression (12-38% of community samples, 33% of clinical samples; boys show greater co-occurrence than girls).
  • Some but not all (estimates of 25%) children continue a course of aggressive and antisocial behaviors into adolescence; early childhood onset is related to more serious and persistent antisocial behaviors; this early onset pattern is less common than the adolescent-onset pattern (3-5% of the general population). These children have often been described as having a “difficult temperament during infancy”.
  • Adolescent-onset pattern is the more common developmental pathway, with slightly more females than males; problematic behaviors often stop after adolescence and are referred to as adolescent-limited.
  • A developmental triple pathway model is provided by the research of Loeber and colleagues: the overt pathway, the covert pathway and the authority conflict pathway.

2. Oppositional Defiant Disorder (313.81):

  • Classifed as an externalizing disorder
  • DSM-IV-TR criteria-
Oppositional Defian Disorder:
  • A pattern of negativism, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
    • (1) often loses temper
    • (2) often argues with adults
    • (3) often actively defies or refuses to comply with adults' requests or rules
    • (4) often deliberately annoys people
    • (5) often blames others for his or her mistakes or misbehavior
    • (6) is often touchy or easily annoyed by others
    • (7) is often angry and resentful
    • (8) is often spiteful or vindictive
      • Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
      • More diagnostic information can be found on the following link from the American Academy of Child & Adolescent Psychiatry: AACAP
  • The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. http://www.wikispaces.com/_/ad4b0f60/i/c.gif
  • 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.
  • Recurrent pattern of negativeistic, defiant, disobedient, and hostile behavior towards authority figures.
  • Occurs ouside of normal developmental levels and lead to impairment in functioning.

  • Peers:
    • Children with oppositional defiant disorder (ODD) have substantially impaired relationships with parents, teachers, and peers. These children are not only impaired in comparison with their peers, scoring more than two standard deviations below the mean on rating scales for social adjustment, but they also show greater social impairment than do children with bipolar disorder, major depression, and multiple anxiety disorders. When compared with oppositional defiant disorder, only conduct disorder and pervasive developmental disorder had nonstatistical differences in social adjustments.

  • Associated features:
    • Oppositional Defiant Disorder (ODD) is characterized by hostile and defiant behaviors, such as negativity, defiance, hostility, frequent outbursts of rage, an excessive need to argue and swear, avoidance, and disobedience that begin by age six and is followed by Conduct Disorder (CD) that has an early onset around age nine. Those who develop CD in adolescence have problems that persist through adolescence, but are not seen in adulthood. These children seem to be most comfortable when pushing the boundaries of familiar territory.
    • According to the DSM-TR-IV, Oppositional Defiant Disorder (ODD) is more common in households where the child's upbringing has been very inconsistent or even neglectful and tends to shift into the school environment. The child's caregiver might also change often during their life. Children with Oppositional Defiant Disorder (ODD) might also have Attention-Deficit/ Hyperactivity Disorder (ADHD) or other Learning Disorders (LD) and Communication Disorders. Males in their preschool years tend to have higher motor activity or a more problematic temperament. During school years children with Oppositional Defiant Disorder (ODD) may have lower self-esteem and low frustration tolerance. They may also swear and use alcohol, tobacco, or illegal drugs. They may often invoke conflict with teachers, parents, and even peers. Difficulty maintaining friendships and academic problems are also seen quite frequently with this disorder.
    • ODD usually begins in the child's home and often carries over to familiar adults in the child's life such as his/her parents. With these adults they will push the boundaries and test their limits. Children with ODD may present either a low self-concept or an inflated self-esteem. They often engage their parents or caregivers in fights that may escalate into emotional turmoil on both child and parents which can lead parents to start a negative style of parenting that often only serves to perpetuate the problem. ODD behaviors may not be evident in the school or community and are not likely to be evident in the clinical interview.
    • It occurs outside of normal development levels and leads to impairment in functioning.

  • Child vs. adult presentation:
    • Oppositional behavior is common in preschool children and adolescents, therefore, the caution should be determined for an adequate diagnosis. The number of symptoms tends to increase with age. Children tend to display disruptive and aggressive behaviors for longer than 6 months. There is a pattern of ongoing defiant, uncooperative, and hostile behaviors. Children usually have frequent temper tantrums, deliberate attempts to upset or annoy people especially adults, and they seek revenge often. If the Oppositional Defiant Disorder (ODD) does not progress into Antisocial Personality Disorder (ASPD), then the problems continue through adolescence, but will not be seen in adulthood. Research has demonstrated that children, who have Oppositional Defiant Disorder (ODD), especially at an early age, are more likely to develop Antisocial Personality Disorder (ASPD), psychopathy, or other serious mental illness when they reach adulthood.

  • Gender and cultural differences in presentation:
    • Before puberty, males seem to have Oppositional Defiant Disorder (ODD) more often than females. It is a 4:1 agverage ratio that males have ODD more than girls. After puberty, the rates will equal out. Symptoms for both genders are very similar, except that males will sometimes be more confrontational or have more persistent symptoms. The presentation of ODD symptoms may be seen differently across cultures.

  • Epidemiology:
    • Oppositional Defiant Disorder (ODD) seems to be more common in families where at least one parent has had a history of Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Mood Disorder, Attention Deficit/Hyperactivity Disorder (ADHD), Substance-Related Disorder, or Antisocial Personality Disorder. Also, some studies have shown that children that have mothers with Depressive Disorder are more likely to have oppositional behavior. It is unknown as to how much the mother's depression results from or causes the child's oppositional behavior.
    • Rates of 2% to 16% have been reported.
    • Symptoms usually become evident before eight years of age and not later than early adolescence. Oppositional symptoms often emerge at home but may emerge elsewhere as well over time. Onset is usually gradual, over months or years. Oppositional Defiant Disorder (ODD) may be a precursor to Conduct Disorder (CD).

  • Etiology:
    • There are many different theories that try to explain both Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD):
      • A psychodynamic oriented therapist would interpret the aggressive and defiant behaviors of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) as manifestations of a deeply-seated feeling of lack of parental love, the inability to trust, and an absence of empathy. This is related to the Psychodynamic disorders.
      • Behavioral Theories suggest that the defiant behaviors are caused by the defiant behavior not being punished and good behavior being reinforced. The parents repeatedly giving into demands is a reinforcement of the bad behavior.
      • Cognitive Theories suggest that the child feels hostility in their lives, and they responded to it with their own hostility.
      • Family Patterns, Attachment, and Parenting a Family System Clinician would say that the child's aggression is their way of attempting to control the balance of power because of the parents inconsistent, or extreme boundaries and limit setting.
      • There is also evidence of low levels of DBH (which converts dopamine to noradrenaline) may produce higher thresholds for sensation-seeking behaviors in some children.

  • Empirically supported treatments:
    • Problem-Solving – Skills-Training programs teach children to solve problems in a logical and predictable manner. The second, The Coping Power, promotes anger control. The down side to both is the time with Problem-Solving – Skills-Training being a 20 session program and The Coping Power being even longer at 33 sessions. There is also research being done in parenting training to help parents improve skills in targeting behaviors that should be changed and developing a reward program to reduce unwanted behaviors while increasing the wanted ones.
    • Parent Management Training (PMT) can allow the parents learn to develop and implement structured contingency management programs at home. It can improve interactions between the parents and child, change antecedents to problem behaviors, improve the parent's monitoring skills of the child's behavior, and give them more effective discipline strategies. A few examples of the techniques suggested towards parents during this training, are to acknowledge and praise children when they perform positive behaviors, establish schedules and stick to them, maintain effective timeouts, and try to circumvent corrivalry.
  • -- Individuals raising children with Oppositional Defiant Disorder (ODD) must find ways to accomplish thier daily routines and errands dispite the behavior of thier children. Without the perspective of being a parent of a child with ODD it can be difficult to understand the challenges they face. See video http://www.youtube.com/watch?v=c-KC9tkn0_Y
    • Recent studies demonstrate that certain medications can help with Oppositional Defiant Disorder (ODD). The research is preliminary, but the studies show that under certain circumstances medical treatments may help.
      In one study, Ritalin (**methylphenidate** hydrochloride) was used to treat children with both ADHD and ODD. Researchers found that when treated with Ritalin, 90% of the children no longer had the ODD. However, this was a poorly executed study. The researchers dropped a number of children from the study because they were too defiant to take their medication as scheduled. Still, even if these children are included as treatment failures, the study still showed a 75% success rate with Ritalin (Kane, 2010). For children that are over 6 years old take Ritalin starting out with 5mg tablets twice a day. It should be taken in the morning before breakfast and in the afternoon before dinner to avoid stomach problems. If necessary, your child's healthcare provider may slowly increase the dosage up to Ritalin 60 mg per day. For adults with narcolepsy, the total dosage of Ritalin per day is usually 20 mg to 30 mg (divided into two or three doses). Some people may need less Ritalin, while others may need as much as 60 mg per day.
  • As with any medicine, side effects are possible with **Ritalin** (**methylphenidate** hydrochloride). However, not everyone who takes the drug will experience side effects. In fact, most people tolerate it quite well. If side effects do occur, in most cases, they are minor, meaning they require no treatment or are easily treated by you or your healthcare provider. Common Side Effects of Ritalin has been studied thoroughly in clinical trials, with many people having been evaluated. In these studies, side effects occurring in a group of people taking the drug are documented and compared to side effects that occurred in a similar group of people not taking the medicine. This way, it is possible to see what side effects occur, how often they appear, and how they compare to the group not taking the medicine. Based on these studies, the most common Ritalin side effects include: nervousness, **Insomnia**, loss of appetite, nausea, dizziness, headache, drowsiness, abdominal pain (stomach pain), and weight loss (see **Ritalin and Weight Loss**). Ritalin can also temporarily stunt the growth of children. This slowing down of growth is usually small (less than an inch and less than two pounds), and children usually catch up to their normal growth rate with time.
  • DON'T FORGET: A diagnosis of ODD must occur before the age of 18, and symptoms must not be better accounted for by either conduct disorder or anitsocial personality disorder.
  • Children With Oppositional Defiant Disorder
http://www.aacap.org/cs/root/facts_for_families/children_with_oppositional_defiant_disorder

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3. Conduct Disorder (CD), Childhood-Onset Type (312.81):

  • Classified as an externalizing disorder. More severe than operational defiant disorder.
  • Children with Conduct Disorder (CD) are usually rejected by their peers and usually have a hard time making friends.
  • DSM-IV-TR criteria-
  • Conduct Disorder:
    • Conduct disorder is a more extreme form of ODD and involves more serious incidents of aggression and defiance.
    • A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules that are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months.
      • Aggressive conduct that threatens physical harm.
      • Nonaggressive conduct that causes property damage.
      • Deceitfulness or theft.
      • Serious violations of rules.
  • The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
  • If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
  • Coding note: Onset of at least one criterion characteristic of Conduct Disorder (CD) prior to age 10 years.
  • Aggression to People and Animals:
    • Often bullies, threatens, or intimidates others.
    • Often initiates physical fights.
    • Has used a weapon that can cause serious physical harm to others.
      • `A bat, brick, broken bottle, knife, gun
    • Has been physically cruel to people.
    • Has been physically cruel to animals.
    • Has stolen wile confronting a victim.
      • Mugging, purse snatching, extortion, armed robbery
    • Has forced someone into sexual activity.

  • CD Subtypes:
    • Child-Onset Type:
      • Onset of at least one criteria before age 10.
    • Adolescent-Onset Type:
      • Absence of any criteria before age 10.
    • Unspecified Onset
    • Code Severity:
      • Mild, Moderate, and Sever.

  • Associated features:
    • Children with Conduct Disorder (CD) show acts of aggression towards others and animals. Children with conduct disorder (CD) usually show little to no compassion or concern for others or their feelings. Also, concern for the well-being of others is at a minimum. Children also perceive the actions and intentions of others as harmful and threatening than they actually are and respond with what they feel is reasonable and justified aggression. They may lack feelings of guilt or remorse. Since these individuals learn that expressing guilt or remorse may help in avoiding or lessening punishment, it may be difficult to evaluate when their guilt or remorse is genuine. Individuals will also try and place blame on others for the wrong doings that they had committed. Children with conduct disorders (CD) tend to have lower levels of self-esteem. Children diagnosed with conduct disorders (CD) are typically characterized as being easily irritable and often reckless, as well as having many temper tantrums. These children may force sexual activity and theft while confrontion (e.g. mugging).
    • Individuals may have low self-esteem despite their projected "tough" image portrayed to society. Conduct Disorder (CD) often accompanies early onset of sexual behavior, drinking, smoking, use of illegal drugs, and reckless acts. Illegal drug use may increase the risk of the disorder persisting. The disorder may lead to school suspension or expulsion, problems at work, legal difficulties, STD's, unplanned pregnancy, and injury from fights or accidents. Suicidal ideation and attempts occur at a higher rate than expected.
    • They show aggressive conduct that threatens physical harm, and non-aggressive conduct that causes property damage. They display deceitfulness or theft, and serious rule violations. Rule violations sometimes include staying out all night, running away, and frequently playing truant. There are behavior problems that cause significant impairment in social, academic, or occupational functioning. There is a deliberate engagement in fire setting, with the intention of causing serious damage. They have deliberately destroyed others' property by means other than fire setting. Often children with this disorder will lose their temper easily, argue with adults, and deliberately annoy others.
    • Conduct Disorder (CD) may be accompanied by a lower-than-average intelligence, particularly regarding verbal IQ. Attention-Deficit/Hyperactivity Disorder (ADHD) is common in individuals with this disorder, and the disorder may be comorbid with Learning Disorders (LD), Anxiety Disorders, Mood Disorders, and Substance-Related Disorders.
  • Research has suggested that parents of children with conduct disorder (CD) frequently lack several important parenting skills. Parents have been reported to be more violent and critical in their use of discipline, more inconsistent, erratic, permissive, less likely to monitor their children, as well as more likely to punish pro-social behaviours, and to reinforce negative behaviours. A coercive process is set in motion during which a child escapes or avoids being criticised by his or her parents through producing an increased number of negative behaviours. These behaviours lead to increasingly aversive parental reactions which serve to reinforce the negative behaviours (Duff, 2005).
    Differences in affect have also been noted in conduct disordered (CD) in children. In general their affect is less positive, they appear to be depressed, and are less reinforcing to their parents. These attributes can set the scene for the cycle of aversive interactions between parents and children (Duff, 2005).

  • Child vs. adult presentation:
    • The presentation of symptoms differ among age. As the individual matures, behaviors intensify and become more physical. Less severe behaviors tend to appear first while others emerge later. The most severe appear last. In comparison, childhood-onset presentation involves more behavioral problems. Lying, shoplifting, and burglary are just a few examples of symptoms present among adults.

  • Gender and cultural differences in presentation:
    • Boys tend to display behavioral problems that are associated with conduct disorders than girls. Studies show findings that there is a 4:1 prevalence ratio of CD in boys to girls. However, this ratio may fluctuate throughout the child's development. For example, the difference in prevalence among boys and girls may be small to nonexistent in preschool children, but the difference usually becomes more dramatic throughout childhood. The ration then seems to drops to 2:1 (males to females) during adolescence. There is a bit of controversy about the difference in prevalence rates among boys and girls. Some argue that girls are less likely to be diagnosed with CD because they may exhibit more indirect or relational aggression. Others argue that girls showing possible symptoms of CD should be diagnosed using more lenient criteria that compares a girl to other girls, instead of a sample of both girls and boys.
    • There is some research that has indicated that certain social factors can influence the development of this disorder. For example, the high rate of violence in the United States (compared to other industrialized nations), and the marginalization of ethnic minorities have been noted to increase the risk of delinquent and antisocial behavior among those without the means to obtain goods through socially accepted methods. However, the findings of these studies are not conclusive.
    • Boys diagnosed with CD tend to display more serious acts such as vandalism and theft. Whereas girls tend to display acts such as running away, truancy, and prostitution.

  • Epidemiology:
    • The diagnosis range of individuals with conduct disorder are anywhere from 1% to no more than 10%. Also, conduct disorder (CD) ranges in 9 to 17 year old kids at about 1% to 4%.The prevalence rate of males is higher than that of females. Research has showed that the prevalence of CD has increased.
    • Onset may occur as early as preschool, but the most significant symptoms usually appear from middle childhood through middle adolescence. Oppositional Defiant Disorder (ODD) is a common precursor to Conduct Disorder (CD). Onset after 16 years of age is rare. The course varies; in the majority of individuals, it remits by adulthood. A large portion continues to show that meet criteria for Antisocial Personality Disorder. Many achieve adequate social and occupational adjustment as adults. Early onset predicts a worse prognosis and an increased risk for Antisocial Personality Disorder and Substance-Related Disorders. Those with Conduct Disorder (CD) are at risk for Somatoform Disorders, Mood Disorders, and Anxiety Disorders as well.

  • Etiology:
    • The etiology of conduct disorders (CD) is thought to be mostly family influenced and morally developed. Studies have shown that there is a high incidence rate of deviant behavior among families of children with conduct disorder. Also, moral development relates to the violating of rules and norms that is portrayed among conduct disorder. These behavioral characteristics pertain to moral development.
    • Social problems and peer group rejection have been found to contribute to delinquency. Low socioeconomic status has been associated with conduct disorders. Children and adolescents exhibiting delinquent and aggressive behaviors have distinctive cognitive and psychological profiles when compared to children with other Mental Health Disorders problems and control groups.
    • A decrease of activity in frontal lobe functioning has been associated with poor ability to inhabit behavioral responses. This also leads to a weakness in planning ability.

  • Empirically supported treatments:
    • Educating the parents of children with conduct disorders (CD) and providing them with information on the disorder are well-established treatments. Also, modifying the behavior in the classroom can be an effective treatment modality in children with conduct disorder (CD).
    • Certain cognitive-behavioral approaches have been proven to be effective when working with children that have CD. It has been documented that children with CD have problems processing social information. This may include difficulty encoding social cues, interpreting these cues, developing social goals, and developing appropriate social responses. These cognitive-behavioral techniques are designed specifically to help children overcome these deficiencies in social cognition and social problem solving.
    • Family therapy helps families gain an understanding of the problems with conduct disorder and how they can be corrected. Therapists evaluate how different family members interact in a therapy type environment. Typically, family therapy is directed towards helping parents work together as a whole, help them cope more efficiently, and to equip parents with better disciplinary skills.
  • Note: CD with choldhood-onset-type applies if at least one criterion symptom was present prior to 10 years of age, while CD with adolescent-onset-type is used if no symptoms were evident prior to 10 years of age.




Summary:
Conduct disorder (CD) is very common among children and adolescents in our society. This disorder not only affects the individual, but his or her family and surrounding environment. Conduct disorder (CD) appears in various forms, and a combination of factors appear to contribute to its development and maintenance. A variety of interventions have been put forward to reduce the prevalence and incidence of conduct disorder (CD). The optimum method appears to be an integrated approach that considers both the child and the family, within a variety of contexts throughout the developmental stages of the child and family's life (Duff, 2005).
http://www.aacap.org/cs/root/facts_for_families/conduct_disorder

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4. Attention-Deficit/Hyperactivity Disorder:

There are two types of ADHD: 1) Inattentive Type, and 2) Hyperactive-Impulsive Type.
  • DSM-IV-TR criteria:
  • Inattentive Type and Hyperactive-Impulsive Type:
    • 1. Inattentive Type:
    • Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
      1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
      2) Often has trouble keeping attention on tasks or play activities.
      3) Often does not seem to listen when spoken to directly.
      4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
      5) Often has trouble organizing activities.
      6) Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
      7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
      8) Is often easily distracted.
      9)Often forgetful in daily activities.
    • Attention can mean a number of different things.
    • In ADHD, the main problem is the inability to have sustained attention or persistence on tasks, remember and follow rules and resist distractions.
      • May be more related to working memory than true "attention" problems.
    • People with ADHD exhibit more "off-task" time and less productivity.
    • Even occurs during things like television.

    • 2. Hyperactive-Impulsive Type:
      • Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
        Hyperactivity:
        1) Often fidgets with hands or feet or squirms in seat.
        2) Often gets up from seat when remaining in seat is expected.
        3) Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
        4) Often has trouble playing or enjoying leisure activities quietly.
        Is often "on the go" or often acts as if "driven by a motor".
        5) Often talks excessively.
        Impulsiveness:
        6) Often blurts out answers before questions have been finished.
        7) Often has trouble waiting one's turn.
        8) Often interrupts or intrudes on others (e.g., butts into conversations or games).
  • Some symptoms that cause impairment were present before age 7 years. There has to be an onset of symptoms prior to 7 years old, but a diagnosis can occur much later.
  • Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
  • There must be clear evidence of significant impairment in social, school, or work functioning.
  • The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
  • Don't forget: Children who meet the criteria for both inattentive type and hyperactive-impulsive type meet the criteria for ADHD Combined Type.

  • ADHD Subtypes:
    • ADHD, Combined Type:
      • If both criteria for inattentive and hyper-impulsive symptoms are met for the past 6 months.
    • ADHD, Predominantly Inattentive Type:
      • If criterion for inattentive is met but criterion for hyper-impulsive is not met for the past 6 months.
    • ADHD, Predominantly Hyperactive-Impulsive Type:
      • If criterion for hyper-impulsive is met but criterion for inattentive is not met for the past 6 months.
    • Evidence mountng that predominately inattentive type is a separate disorder:
      • Sluggish cognitive style, selective attention deficits.
      • Lower rates of co-morbidity with ODD and CD.
      • Memory retrieval problems.
      • Different development course.

  • Peers:
    • One effect Attention-Deficit/Hyperactivity Disorder (ADHD) can have on a child’s life is to make childhood friendships, or peer relationships, very difficult. These relationships contribute to children’s immediate happiness and may be very important to their long-term development.
    • Research suggests that children with difficulty in their peer relationships, like being rejected by peers or not having a close friend, may in some cases have higher risk for anxiety, behavioral and mood disorders, substance abuse and delinquency as teenagers.
    • Parents of children with ADHD may be much less likely to report that their child plays with groups of friends or is involved in after-school activities, and half as likely to report that their child has many good friends. Parents of children with ADHD may be more than twice as likely than other parents to report that their child is picked on at school or has trouble getting along with other children.

  • Associated features:
    • There are three core features of ADHD. They are inattention, hyperactivity and impulsivity. Attention Deficit/Hyperactivity Disorder (ADHD) can be seen in both children and adults even though it is more prevalent in children. The onset of ADHD is usually before the age of seven. People with ADHD have to demonstrate at least one of three core features of the disorder: inattention, hyperactivity, and impulsive. Given these features, there are three subtypes of ADHD: Primarily Inattentive Type, Primarily Hyperactive-Impulsive Type, and Combined Type. Due to random cases and unique patients, the DSM-IV-TR includes an additional category, ADHD NOS (Not Otherwise Specified). This category is most often used in cases where the onset of ADHD occurs after seven years of age or when hypo-active behaviors accompany inattentive symptoms. The Inattentive Type of ADHD is characterized by poor organizational skills, poor ability to maintain mental focus, poor attention to details, forgetfulness, etc. Also the Inattentive type is the criterion for predominately inn-attentive type is met but not the hyperactive impulsive type for the past six months. The Hyperactive-Impulsive Type of ADHD is characterized by fidgety behavior, non-stop motion, excessive talking, blurting out thoughts and answers, impatience, etc. This type is predominately met if criterion for hyper impulsive type is met but inattentive criterion is not met for the past six months. The DSM-IV-TR requires six of the nine listed symptoms for a diagnosis of Inattentive Type or Hyperactive-Impulsive Type. In addition, the DSM requires the child to meet four other conditions: symptoms must be present for at least six months, symptoms must cause problems with everyday life, symptoms must stay steady over different situations, and symptoms must occur before seven years of age. Children with this type of ADHD have difficulties with certain impulses, such as waiting their turn, which puts them at a greater risk socially with their peers. These children often have trouble maintaining friendships and tend to gravitate towards other children who exude disruptive behavior. Children who meet the qualifications and symptoms for the past six months for both Inattentive Type and Hyperactive-Impulsive Type ADHD are diagnosed with Combined Type ADHD.
    • The main problem is the inability to have sustained attention or persistence on tasks, remembering and following rules, and resisting distractions. This may be more related to working memory than true attention problems. These individuals display more off-task time and less productivity, even with television. In ADHD, thought to involve problems with voluntary inhibition of responses, not impulsively due to motivators. Some impairment from the symptoms is present in two or more settings, at school or work and home. There must be clear evidence of significant impairment in social, school, or work functioning.
    • Their are subtypes of ADHD that need to be recognized: Combined Type (if both criteria for inattentive and hyper-impulsive symptoms are met for past 6 months), Predominantly Inattentive Type (criteria for inattentive is met, but not hyper-impulsive criteria met for past 6 months), and lastly Predominantly Hyperactive-Impulsive Type (vice verse criteria as for Inattentive Type).

  • Child vs. adult presentation:
    • ADHD is more prevalent in children, but it can also occur in adults. When present in adults, it is categorized as Adult Attention Deficit Disorder (AADD). The symptoms for AADD and ADHD are fairly similar. For example, AADD is characterized as having low self-motivation and low self-regulation due to procrastination, organization problems, problems being easily distracted, etc. Studies show that 70 percent of children diagnosed with ADHD will continue to have related symptoms into and possibly throughout adulthood. At some level, all of the core symptoms are present in all children. It is a very normal thing to be a kid and that involves a lot of random behaviors and spurts of likes and dislikes. The degree of the symptoms and the impairment they cause separates ADHD from ordinary exuberance. Symptom thresholds may not apply outside 4 to 16 year old range. The behavior of hyperactivity can be seen in 22% to 57% of children and only 4.2% to 6.3% meet criteria for the actual disorder. Parent reports are much lower than the reports by the teachers.

  • Gender and cultural differences in presentation:
    • Regarding ratios of male to female, there have been assorted reports of ADHD ranging from 2:1 to 9:1. In other words, ADHD is seen two to four times more in boys than girls. Males are 2.6% to 5.6% time more likely to be diagnosed as females. Clinic referred samples have an even higher ratio due to co-morbid ODD/CD. Males and females tend to have the same functional deficits and impairments. Although recent studies have shown that children who express Inattentive Type ADHD symptoms are more likely to be female, experts are still debating whether prevalence rates indicate gender differences. ADHD is viewed differently across cultures. For example, some cultures view ADHD as it is described in the DSM-IV-TR. On the other hand, some cultures see it on a biological level and portray ADHD symptoms as character flaws. Studies show that Africa and the Middle East have lower prevalence rates of children diagnosed with ADHD than children diagnosed in North America.

  • Epidemiology:
    • Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common childhood mental disorders. Prevalence rates of ADHD in school-aged children, according to the DSM-IV-TR, runs from three to seven percent of the total population. In other words, three to seven percent of school-aged children will be diagnosed with one of the three types of ADHD. The Hyperactive-Impulsive Type of ADHD consumes ninety percent of these children. This could be due to the fact that most children showing symptoms of the Inattentive Type of ADHD are undiagnosed because of their passive and subtle behavior. Children with ADHD usually experience academic problems as well. It is estimated that comorbid rates between ADHD and specific learning disabilities are anywhere from 16 to 21 percent. It is important to note that symptoms of childhood depression and Bipolar Disorder often overlap with symptoms of ADHD. For example, irritability is one of the most common symptoms of childhood depression. Irritability can cause problems concentrating, agitation, frequent squirming, etc. Studies show that 70 percent of depressed children and 90 percent of younger children and 30 percent of adolescent children with Bipolar Disorder have co-morbid ADHD. ADHD and externalizing disorders also have co-morbid rates. Studies show that co-morbid rates between children with ADHD and ODD (Oppositional Defiant Disorder) range from 35 to 60 percent. Also, almost half of the children diagnosed with ADHD will develop CD (Conduct Disorder) later in life. Studies show that hyperactive teens with ADHD are significantly more likely to use cigarettes and alcohol. Lastly, ADHD causes its inhabitants to develop problematic relationships with their peers. This can cause social anxiety along with many other problems. Anxiety symptoms resemble ADHD symptoms and most children with ADHD have sleeping problems.
    • ADHD fits the criterion such as engender substantial harm, and incur dysfunction of mechanisms that have been selected for survival value, and these back up ADHD's realness or validity.
    • The earliest age at which a diagnosis of ADHD might be possible is about three years; symptoms of inattention are not likely to be noticed until much later. About two-thirds of of elementary school children diagnosed with ADHD have an additional diagnosable disorder. The course of this disorder is particularly prone to bad outcomes because of high rates of comorbidity with internalizing and externalizing disorders.

  • Etiology:
    • The exact cause of ADHD is still debated among experts even though it is one of the most prevalent childhood disorders. The occurrence of ADHD is most likely due to a combination of environmental and biological factors. The biological factors pertain to abnormal brain activity and genetic factors. In children with ADHD, functional resonance imaging (FMRI) and single photon emission computed topography (SPECT) shows that the cingulate gyrus is more active. The cingulate gyrus is responsible for directing response selection and the ability to focus one’s attention. On the other hand, brain scans show that frontal brain activities are less frequent than normal. The frontal brain system is in charge of executive and motor functioning. Another area of abnormal brain activity for children with ADHD is neurotransmission. Studies show that these children have low levels of catecholamines (nor epinephrine, dopamine, and epinephrine). These neurotransmitters are responsible for motor activity and attention. In addition to abnormal brain activity, there are genetic factors in ADHD. Nearly 50 percent of parents who have ADHD have children with this disorder.
        • There is much debate over the symptoms and name for what is now called or referred to as ADHD. Some other names and symptoms are explosive will, minimal brain dysfunction, volatile inhibition, and hyperactive child syndrome. In the DSM III, ADHD was called simply Attention Deficit Disorder.
        • Evidence is mounting that the predominately inattentive type is a separate disorder such as a sluggish cognitive style, lower rates of co-morbidity with ODD and CD., memory retrieval problems, more passive social relationships and a different developmental course.
        • As infants, children with difficult temperaments tend to be at greater risk for developing ADHD later in life.
        • Other early risk factors include excessive activity, difficult sleeping (insomina), and irritability.

  • Empirically supported treatments:
    • Treatments for ADHD can vary between patients according to their comorbid features. Recent studies show that stimulant medication is more effective in reducing the core symptoms of ADHD than behavior therapy. Given this, medication should still be a short-term fix. There are many forms of stimulant medication. For example, Ritalin (Methylphenidate) and Dexedrine are short-acting medications, Ritalin-SR is a slow release medication, and Ritalin-LA is a long-acting medication. Also, stimulant medications such as Ritalin, Cylert (Pemoline), and Dexedrine increase the number of neurotransmitters that ADHD inhibits.
    • Cylert (pemoline) is supplied as tablets containing 18.75 mg, 37.5 mg or 75 mg of pemoline for oral administration. Cylert is also available as chewable tablets containing 37.5 mg of pemoline. Cylert side effects cannot be anticipated. If any develop or change in intensity, inform your doctor as soon as possible. The most common Cylert side effect may include insomnia. Less common Cylert side effects may include depression, dizziness, drowsiness, hallucinations, headache, hepatitis and other liver problems, increased irritability, involuntary, fragmented movements of the face, eyes, lips, tongue, arms, and legs, loss of appetite, mild depression, nausea, seizures, skin rash, stomachache, suppressed growth, uncontrolled vocal outbursts, weight loss, and yellowing of skin or eyes. Rare Cylert side effects may include a rare form of anemia with symptoms such as bleeding gums, bruising, chest pain, fatigue, headache, nosebleeds, and abnormal paleness.
    • Methylphenidate or Ritalin is a central nervous system stimulant. It affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control. Methylphenidate is used to treat attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and narcolepsy. Methylphenidate may also be used for purposes not listed in this medication guide. If a child is taking Ritalin it should be taken 2 times a day; morning before breakfast and at night before dinner. Usually children start out at 6mg tablets and then can move up to at least 60mg a day. Ritalin should not be used in children under six years, since safety and efficacy in this age group have not been established. Sufficient data on safety and efficacy of long-term use of Ritalin in children are not yet available. Although a causal relationship has not been established, suppression of growth (ie, weight gain, and/or height) has been reported with the long-term use of stimulants in children. Therefore, patients requiring long-term therapy should be carefully monitored. Ritalin should be given cautiously to emotionally unstable patients, such as those with a history of drug dependence or alcoholism, because such patients may increase dosage on their own initiative. Chronically abusive use can lead to marked tolerance and psychic dependence with varying degrees of abnormal behavior. Frank psychotic episodes can occur, especially with parental abuse. Careful supervision is required during drug withdrawal, since severe depression as well as the effects of chronic over activity can be unmasked. Long-term follow-up may be required because of the patient's basic personality disturbances.
    • The dose of **Dexedrine**® (**dextroamphetamine** sulfate) prescribed by your healthcare provider will vary depending on a number of factors, including: the condition being treated (**ADHD** or **narcolepsy**), your age, other medical conditions you may have, other medications you may be taking. As is always the case, do not adjust your dose unless your healthcare provider specifically instructs you to do so. Dexedrine Dosing for ADHD; refer to the following table for the Dexedrine dosing for children and teenagers with ADHD:

Age
Dexedrine Dosage
Maximum Dexedrine Dosage

3 to 5 years old
2.5mg once daily (tablet only)
40mg total daily (rarely, dosages may need to be higher)

6 years and older
5 mg once or twice daily (tablets), or 5 10 mg once daily (spansules)
40 mg total daily (rarely, dosage may need to be higher)
    • Generally, the lower dosage of Dexedrine should be tried first. The dosage should be increased slowly and only if necessary.
    • As with any medicine, there are possible side effects with **Dexedrine**® (**dextroamphetamine** sulfate). However, not everyone who takes this medicine will have problems. In fact, most people tolerate it well. When side effects do occur, in most cases they are minor, meaning they require no treatment or are easily treated by you or your healthcare provider. Most common side effects of Dexedrine include: overstimulation, restlessness, or **insomnia**, dizziness, **Headache**, dry mouth, unpleasant taste, **Diarrhea**, **Constipation**, loss of appetite and decreased eating, weight loss (see **Dexedrine and Weight Loss**), and **Erectile dysfunction** (**ED** or **impotence**) or changes in sex drive (see **Dexedrine Sexual Side Effects**). Dexedrine can also cause a temporary slowing of growth in children. This slowing of growth is usually small (less than an inch and less than two pounds), and children usually catch up to within normal limits in time.
    • There are behavioral benefits to stimulant medication too. Studies show that improvements in parent-child interactions and decreases in aggressive behaviors can result from stimulant medications. Studies also show that Parent Training Programs (PT) are effective in that they improve parenting skills while reducing parent stress. Behavior treatment is used and can show improvements in areas such as parent-child interactions, aggressive responses, and social skills. Given the above information, medication is still the most effective treatment for ADHD.

  • Critics:
    • Symptom thresholds may not apply outside 4-16 year old range.
    • Research has found the following recommended levels for different age groups:
      • 4/9 and 5/9 for age 17-29.
      • 4/9 and 4/9 for age 30-49.
      • 3/9 and 3/9 for ages 50+.
      • No research on below age 4.
    • Appropriateness of items sets for different ages and genders.
      • Inattention seem more geared for school-age or adolescents.
      • Hyper/Impulsive seem more applicable to younger children.
    • Could influence rates of diagnosis across age groups, resulting in more false-negative as one gets older.
    • Onset before age 7 not research supported.
      • No other mental disorder has a precise an age of onset.
    • No lower-age or IQ boundary in DSM-IV-TR.
    • No research support for symptom durationof 6 month; some support for a 12 month period.
    • Requirement of impairment 2/3 environments.
      • Situational specificity
      • Lack of parent-teacher agreement
    • Problems likely to be addressed in DSM-V, but can be used for more effective diagnosis now.
    • Many critics of the realisy of ADHD, say that it is merely pathologizing normal behavior.
      • Includes Rush Limbaugh, Psylis Schafly, George Will, Ariana Huffington, Hillary Clinton, and even some actual scientists.
    • If this is true, differences would not be found between ADHD and non-ADHD children.
      • Obviously not the case, 30 years of research on the differences.

  • The MTA study: The Multimodal Treatment Study of Children (MTS) with ADHD is the largest and most comprehensive study done on children with ADHD. A summary of the study is summarized by Dr. David Rabiner, Ph.D at the following link:MTA study.

  • LINKS:
    • Robert Jergen, author of Little Monster: Growing Up with ADHD and professor at the University of Wisconsin, tells about his life as an adult with ADHD.

  • Barkley's model
    • focusus on how behavioral disinhibition impacts four primary executive functions:
      • Poor working memory
      • Delayed interalization of speech
      • Immature regulation of affect/ motivation/ arousal
      • Impaired reconstitution

external image barkley2.jpg

  • Barkley's Assumptions:
    • Behavioral inhibition (BI) develops ahead of these four executive functions (EF).
    • Each EF emerges at different times and has a different developmental trajectory.
    • ADHD impairs the BI, which in turn impairs the EF.
    • Deficit in BI due to biological factors.
    • Deficits in self-regulation are caused by the primary BI, but in turn feed back to cause even poorer BI.
    • Model does not apply to the inattentive type of ADHD.
  • With approximately four million children in the United States it can be difficult to realize the individual nature of ADHD symptoms in children. Each child presents a unique case. See video http://www.youtube.com/watch?v=z2hLa5kDRCA.
  • Journal article: Social cognition in ADHD.
  • Journal article: Genetics of ADHD.
  • A report done by CNN on the over diagnosis of ADHD: CNN report on ADHD.
  • A satirical view of ADHD as shown on Comedy Centrals "The Daily Show", with John Stewart but refer back to the previous information to see correct symptoms and diagnostic criteria for ADHD: Daily Show ADHD> .
  • To learn more about the effects ADHD can have on children with peer interactions, click here.
  • Below is a YouTUBE video of a young boy with ADHD. It shows how even though he has a mental illness he can still perform with music. ADHD does not affect this kid with his music ability.
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5. Disruptive Behavior Disorder Not Otherwise Specified (312.9):

  • DSM-IV-TR criteria:
    This category is for disorders characterized by conduct or oppositional defiant behaviors that do not meet the given criteria for Conduct Disorder (CD) or Oppositional Defiant Disorder (ODD). For example, it includes clinical presentations that do not meet the full criteria for Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD), but in which there is clinically significant impairment. There may be unique circumstances of the child's behavior, or there may not have been enough information collected early to make a full diagnosis. The Disruptive Behavior Disorder NOS allows for examining clinicians to document that a child has a behavior problem, and allows the clinician to make a more precise diagnosis in the future.
  • Empirically Supported Treatments:
    The treatment for Disruptive Behavior Disorders is a combination of specialized Parent Skills training. Parent training and therapy with the child or adolescent tends to be most effective when done in the family home.

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What Causes Disruptive Behavioral Disorders?

  • Research has identified both biological and environmental causes for Disruptive Behavior Disorders. Youngsters most at risk for Oppositional Defiant Disorder (ODD) and Conduct Disorders (CD) are those who have low birth weight, neurological damage or Attention Deficit Hyperactivity Disorder (ADHD). Youngsters may also be at risk if they were rejected by their mothers as babies, separated from their parents and not given good foster care, physically or sexually abused, raised in homes with mothers who were abused, or living in poverty (Disruptive behavioral disorders, 2010).

How can Disruptive Behavior Disorders be treated?

  • Because so many of the factors that cause Disruptive Behavior Disorders happen very early in a child’s life, it is important to recognize the problems as early as possible and get treatment. The treatment that has shown the best results is a combination of:
    • Specialized parent skills training
    • Behavior therapies to teach young people how to control and express feelings in healthy ways
    • Coordination of services with the young person’s school and other involved agencies
    • Parent training and therapy with the child or adolescent, most effective when done in the family home
  • No medications have been consistently useful in reducing the symptoms of Oppositional Defiant Disorder (ODD) or Conduct Disorders (CD). Medications may be helpful to some young people, but they tend to have side effects that must be monitored carefully (Disruptive behvioral disorders, 2010).


References:
Disruptive behavioral disorders. (2010). The mental Health Associtation, 1-2.
Duff, Jacques. (2005). Disruptive behaviour disorder. Behavioral Neurotherapy Clinic, 1-9. Kane, Anthony. (2010). Oppositional defiant disorder treatment. The Home of the Complete Connection Parenting, 1-2.