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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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