Having ADHD with a co-existing disruptive behavior disorder (ODD/CD) can complicate diagnosis and treatment, and can also worsen the prognosis. Although many children with ADHD eventually adjust, some (particularly those with an associated behavior or oppositional defiant disorder) are more likely to drop out of school, have fewer years of general education, are less satisfied with work, and perform worse as adults at the diagnosis and treating these disorders is by far the best defense against these poorer outcomes.
What types of disruptive behavioral disorders are there?
Disturbing Behavior Disordersinclude two similar disorders: oppositional defiant disorder (ODD) and conduct disorder (CD). Common symptoms seen in children with these disorders include defiance of authority figures, outbursts of anger, and other antisocial behaviors such as lying and stealing. It is believed that the difference between oppositional defiant disorder and conduct disorder lies in the severity of the symptoms and that they may lie on a continuum, often with a developmental progression from ODD to CD with age.
Oppositional Defiant Disorder (ODD)refers to a recurring pattern of negative, defiant, disobedient, and hostile behavior toward authority figures that lasts at least six months. To be diagnosed with ODD, four (or more) of the following symptoms must be present:
- often loses his temper
- often argues with adults
- Often actively resists or refuses to comply with adult demands or rules
- often intentionally annoys people
- often blames others for his mistakes or misconduct
- is often touchy or easily annoyed by others
- is often angry and resentful
- is often spiteful or vengeful.
These behaviors must be more common than other children of the same age and cause significant impairment in social, academic, or occupational functioning to justify the diagnosis.
conduct disorder (CD)includes more serious behaviors, including aggression toward people or animals, destruction of property, lying, stealing, and truancy. The behaviors associated with celiac disease are often referred to as delinquency. Children exhibiting these behaviors should be evaluated extensively.
Children and teens with ADHD and CD often have more difficult lives and poorer outcomes than children with ADHD alone.
Occurrence of ADHD and ODD or CD
About one-third to one-half of all children with ADHD may also have oppositional defiant disorder (ODD). These children are often disobedient and have outbursts of anger. The rate of children meeting all diagnostic criteria for ODD is similar across age groups. Men have a greater incidence of ADHD and ODD, as do children of divorced parents and mothers of low socioeconomic status. Children with the mixed ADHD subtype seem more likely to have ODD.
In some cases, children with ADHD may eventually develop conduct disorder (CD), a more serious pattern of antisocial behavior. A conduct disorder can occur in 25 percent of children and 45 percent of adolescents with ADHD. CD is more common in boys than girls and increases in prevalence with age. Children with ADHD who also meet the diagnostic criteria for celiac disease are twice as likely to have reading difficulties and are at greater risk of social and emotional problems. Problems with nonaggressive behavior increase with age, while aggressive symptoms become less common.
Given the high co-occurrence of ADHD with disruptive behaviors, all children with ADHD symptoms and disruptive behaviors need to be evaluated for the possibility that ODD or CD may be present in addition to ADHD.
Risks of ADHD and a disruptive behavior disorder
Children with ADHD and CD are often at greater risk of exposure to the police and court system than children with ADHD alone. These children often lie or steal and tend to disregard the well-being of others. They also risk serious problems at school or with the police. The risk of legal trouble may be due to the symptoms of CD rather than ADHD.
Disruptive behavioral disorders and untreated ADHD have been found to lead to an increased risk of substance use disorders. Additionally, adolescents with disruptive behavioral disorders and ADHD are more likely to be aggressive and hostile in their interactions with others, and to be arrested. It has also been suggested that the greater impulsiveness associated with ADHD may lead to greater antisocial behavior and its consequences. Therefore, early detection and treatment of both ADHD and disruptive behaviors in children is essential.
Treatment of ADHD and disruptive behavior disorders
All children with symptoms of ADHD and ODD/CD need to be evaluated so that both types of problem behavior can be addressed. These children are difficult to live with and parents need to understand that they do not have to deal with their ADHD and ODD/CD child alone. Interventions such as parent training at home and behavioral support at school can make a difference, and parents should not hesitate to ask for support.
interventions at home
Parent Training (PT): Parent training has been shown to be effective in treating unruly and defiant behavior. Standardized parent training programs are short-term interventions that teach parents specific strategies, including positive participation, ignoring, the effective use of rewards and punishments, symbolic savings, and time-outs to address clinically significant behavior problems. Such training programs may include regular refresher sessions.
Severe cases of CD may require multisystemic therapy, intensive family and community-based treatment that addresses the multiple causes of serious antisocial behavior in adolescence. This approach is very comprehensive and demanding. The therapist using such an approach must have access to developmental and clinical expertise. These intervention services are offered in a variety of settings, e.g. B. at home, at school and in peer groups. Academic and school issues are included, and some therapists work directly with an entire peer group to influence change.
Parent-child interaction therapy is a treatment that teaches parents how to strengthen the relationship with their child and learn behavior management techniques. It has proven long-term effectiveness in young children with ODD and ADHD. Three to six years after treatment, mothers of children with these disorders reported that their children's changes in behavior and their own sense of control persisted. The mothers' reports of disruptive behavior decreased over time after treatment.
Collaborative Problem Solving (CPS): Another technique that seems promising for children with ADHD and ODD is collaborative problem solving (CPS). CPS is a treatment that teaches difficult children and adolescents how to deal with frustration and learn to be more flexible and adaptable. Parents and children learn to search for possible solutions, to negotiate, to make decisions and to implement solutions that are acceptable to both. You learn to resolve disagreements with fewer conflicts.
family therapy: A child's behavior often affects the whole family. Parents of children with ADHD often report marital problems. Mothers can be more depressed and siblings can also develop behavior problems. Family therapy is critical to helping a family address these issues and cope with the reality of having a child with ADHD and disruptive behaviors. Finding a counselor or family therapist in your neighborhood can help the whole family address these issues.
School-wide positive behavior support:Along with the home environment, school can have a significant impact on a child's behavioral patterns. Many school systems now have programs in place to provide school-wide positive behavior support. The goal of these programs is to promote both successful social behavior and academic achievement for all students. These programs consist of: (1) clear, consistent consequences for inappropriate behavior; (2) positive contingencies for appropriate behavior; and (3) team-based services for those students with the more extreme behavioral needs.
Teach:Children's ADHD symptoms, as well as oppositional symptoms, were found to be significantly less in one-to-one tutoring sessions than in the classroom.
classroom management: Providing appropriate instructional support in the classroom can also reduce disruptive behavior. These include: creating an accepting and supportive classroom environment, fostering social and emotional skills, establishing clear rules and procedures, monitoring children's behavior, using rewards effectively, responding to mild problem behavior consistently and effectively, managing anger or aggressive behavior.
The aggregate results from multiple clinical trials indicate that medications used to treat ADHD (both stimulants and non-stimulants) remain an important component in the management of ADHD and co-existing ODD/CD. Children with these disorders treated with these drugs were not only more alert, but less antisocial and aggressive. ADHD medications are often effective treatments for aggressive or antisocial behavior in patients with ADHD and certainly play a role in any treatment program. SeeDealing with medication for children with ADHDfor more informations.
In addition to using stimulants alone, drug combinations appear to be very effective in reducing behavioral and behavioral symptoms associated with attention-deficit/hyperactivity disorder. Several studies reported that this treatment combination was well tolerated and the adverse effects were transient.
What can a parent do?
To increase the chances of a successful future and to prevent criminal behavior in children with ADHD, diagnosis and intervention are extremely important. It is important that parents provide structure and encourage appropriate behavior. Additionally, a positive behavior management plan is important to reduce antisocial behavior. Parents should discuss their child's behavioral symptoms with the pediatrician or family doctor, and consult a psychologist who can suggest effective parenting strategies.
In addition, parents should contact their child's school counselor or school psychologist to discuss possible interventions to improve behavior at school. When the counselor or psychologist assists the teacher in managing behaviors in the classroom, this often leads to significant behavioral changes and reduces the incidence of exclusion. Consistent behavior management at home, at school and elsewhere must be enforced.
For more information and further reading
Barkley, Russel. (1998).Your defiant child: 8 steps to better behavior. New York, NY: Guilford Press. This book is divided into two parts, Getting to Know Your Defiant Child and Coping With Your Defiant Child. Part two contains an eight-step educational program built on consistency.
Clark, Lynn. (1996)SOS! help for parents. Berkeley, CA: Parent Press. This book helps parents learn methods to help children improve their behavior and techniques to help a variety of child personalities, from the stubborn and wayward child to the basics of time-out. It focuses on the basic skills of time out and how parents can use these techniques to encourage a child's behavior change.
Forgatch, Marion S., and Gerald R. Patterson. (2005)Living together of parents and young people: problem solving in the family.Champaign, IL: Research Press. This book teaches parents how to improve their communication and problem-solving skills, host family reunions, and involve the whole family in problem-solving. It explains how parents can teach their teenage children to be responsible about schoolwork, sexual behavior, drugs and alcohol.
Goldstein, Sam; Robert Brooks and Sharon K Weiss. (2004)Angry Kids, Concerned Parents: Seven Steps to Help Families Deal with Anger. Plantation, FL: Specialty Press. This book helps parents deal with their children's anger. It presents the following seven steps to help children deal with anger: (1) understand why children get angry; (2) determine when your child needs help; (3) help the child become an active participant in the process; (4) use strategies to manage and express anger; (5) develop and implement a daily management plan; (6) evaluate and solve problems; and (7) instill a resilient mindset in the child.