Behavior Disorders that often co-occur with ADHD

David Rabiner, Ph.D. Research Professor, Duke University


     




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David Rabiner, Ph.D.
Duke University

(Note: If you are looking for information on Attention Deficit  Disorder (ADD) please be aware that much of what is discussed below should also be relevant.  Technically, the term ADD is no longer used.  Instead, children who have the inattentive symptoms of ADHD but who do not show hyperactive/impulsive symptoms are now diagnosed with ADHD, Predominantly Inattentive Type rather than with ADD.  These terms mean pretty much the same thing but the latter is no longer technically correct.)


One of the most important thing to know about ADHD is that children with ADHD are at increased risk for developing other types of behavior disorders, including Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). The reason this is so important is that when this occurs, the long-term outcomes for children are likely to be much worse than for a child who has ADHD alone. The information below is intended to provide your with an overview of the diagnostic criteria for these conditions and how they differ from ADHD.

Oppositional Defiant Disorder (ODD)

Listed below are DSM-IV symptoms for ODD:

1. often loses temper;
2. often argues with adults;
3. often actively defies or refuses to comply with adult requests or rules;
4. often deliberately annoys people;
5. often blames others for mistakes or misbehavior;
6. is often touchy or easily annoyed by others;
7. is often angry and resentful;
8. is often spiteful and vindictive;

For ODD to be an appropriate diagnosis, at least 4 of the symptoms listed above must be present for at least 6 months; the behavior must occur more frequently than is typical child of comparable age, and the behavior must create significant impairment in a child's social or academic functioning. In addition, the oppositional behavior can not occur only during times when a child is depressed.

An important difference that you will note from the symptoms of ADHD is that none of the ADHD symptoms involve behavior that is considered to be deliberate and willful. Although children with ADHD often engage in behavior that annoy others and fail to follow through on requests, such behavior is generally not deliberately and willfully initiated.

The kinds of difficulties that are associated with ODD are critically important to bring under control as soon as possible, because such behavior becomes more entrenched and difficult to change the longer it persists. In addition, children with ODD are at significant risk for the development of the more severe kinds of behavioral disturbance that is characteristic of Conduct Disorder, and the long term outcomes for children with Conduct Disorder are especially worrisome.

Conduct Disorder (CD)

Conduct Disorder (CD) is a more severe type of behavioral disorder than ODD that is also unfortunately more likely to develop in children with ADHD.

According to DSM-IV, the publication of the American Psychiatric Association that provides current diagnostic criteria for all recognized psychiatric disorders, the essential feature of CD is "...a repetitive and persistent pattern of behavior in which the basic rights of others or age appropriate social norms or rules are violated." These behaviors fall into 4 main groupings:

1. Aggressive behavior that causes or threatens to cause harm;

Examples: initiating fights; cruelty to people or animals;

2. Non-aggressive conduct that causes property loss or damage;

Examples: fire setting with intent to cause damage; deliberate destruction of property;

3. Deceitfulness or theft;

Examples: shoplifting; breaking into someone's house; frequent lying to obtain goods or avoid obligations;

4. Serious violation of rules;

Examples: truancy from school; running away from home; staying out at night prior to age 13;

For the diagnosis of CD to be correctly assigned, at least 3 of the specific symptoms must have occurred during the prior 12 months, with at least one criterion present in the last 6 months. In addition, the disturbance in behavior must clearly result in clinically significantly impairment in the child or teen's social, academic, or occupational functioning. These criterion are intended to assure that the diagnosis is not assigned for an isolated antisocial act, but is instead reserved for youth who show a pattern of antisocial behavior over a significant period of time.

Associated Features

In addition to these core diagnostic criteria, individuals with CD often display a number of associated features as well. They often have little empathy or concern for the feelings and wishes of others; they are prone to often misperceive other's intentions towards them as being hostile which can lead them to overreact in a retaliatory, aggressive manner; guilt and remorse over clear misdeeds are often absent, other than feeling badly about having been caught; poor frustration tolerance and irritability are often present, and self esteem is often poor even though an image of "toughness" is often presented. CD is often also associated with the early onset of sexual behavior, substance use and abuse, excessive risk taking, and school suspension. Self-destructive behavior, including suicide, also occur at higher than expected rates. Not surprisingly, school suspensions, dropping out, and poor achievement are also quite common in individuals with CD.

NOTE: It is important to recognize that the explicit symptoms of CD do not really share any overlap with diagnostic criteria for ADHD. These two disorders certainly share many of the "associated features", but the actually symptoms that are used to make the diagnosis for each condition are really quite distinct.

This is why if a child with ADHD is also displaying the types of behaviors that may warrant a CD diagnosis, it is important not to attribute the antisocial behavior to just another facet of the child's ADHD. The danger in doing this is that the child may not receive the necessary and appropriate treatment as a result.

Subtypes of Conduct Disorder

Two different types of CD are currently recognized. The Childhood-Onset Type is defined by the onset of at least on symptom of CD prior to age 10. Thus, even though a child may not meet full diagnostic criteria before age 10, if these criteria are met when the child is 12, and at least one symptom was present (e.g. running away) before 10, the Childhood-Onset Type would apply. Almost all children who meet criteria for childhood-onset CD would have previously been diagnosed with Oppositional Defiant Disorder.

The second subtype of CD is called the Adolescent-Onset Type. This type is applicable to individuals who current meet the diagnosis for CD but who showed no symptoms of CD prior to age 10. Individuals with adolescent-onset CD are less likely to display aggressive behavior and are more likely to have decent peer relationships. Of utmost importance is that adolescent-onset CD less likely to be associated with serious behavior problems that persist into adulthood.

Although CD may occur in children as young as 5-6, it's onset is usually in late childhood or early adolescence. The course of CD is variable: in a majority of individuals, the disorder remits by adulthood. Nonetheless, a substantial percentage continue to display sufficient antisocial behaviors into adulthood to warrant the diagnosis of antisocial personality disorder as young adults. This is most likely to be true as noted above, for individuals whose CD begins early in life and is marked by aggressive behavior.

 
What is the association between ADHD and CD?

Data collected in numerous studies indicates that about 50% of children with ADHD will also develop ODD or CD at some point during their development. An interesting finding has been that although "pure" ADHD (that is, ADHD without either ODD or CD) is quite common in children, the reverse is less likely. In other words, it appears that most children under age 12 who meet criteria for ODD or CD will also be diagnosed with ADHD. In these cases, it appears that the impulsivity and over activity that is characteristic of ADHD children, and the ensuing difficulties this creates in parent- child, teacher-child, and peer relationships, increases the risk for the kind of conflictual interactions that promote the develop of these other disruptive behavior disorders.

THIS IS WHY IT IS SO IMPORTANT THAT PARENTS LEARN ABOUT THE KINDS OF SPECIALIZED BEHAVIOR MANAGEMENT STRATEGIES THAT ARE OFTEN HELPFUL AND NECESSARY FOR CHILDREN WITH ADHD.

Probably the most important thing a parent can do to help promote their child's long term success is to make sure that the proper steps are taken to prevent the development of these more severe behavior disorders that often develop in response to the problems that primary ADHD symptoms can cause.

Here's why. The long term outcomes of children with pure ADHD and with ADHD and CD are very different. For example, in one study in which samples that followed two samples of ADHD children - one with high levels of aggressive behavior and the other without - there were no cases of drug or alcohol abuse at age 14 in the ADHD only group, while for the ADHD aggressive group, over 30% had engaged in substance abuse. In a similar study using different samples of children, approximately 1/3 of ADHD/CD boys had committed multiple crimes as teenagers compared to fewer than 4% of boys who had been diagnosed with ADHD alone.


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