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David Rabiner, Ph.D.
(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
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
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
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.
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.
Subtypes of Conduct Disorder
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.
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
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
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
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
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