Daily Archives: August 22, 2010

Disruptive Behavior: ODD/CD ADHD

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Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), along with the comorbid Attention-Deficit/Hyperactivity Disorders (ADHD), are among the most prevalent and the most treated pathologies globally. Children who exhibit overactive, noncompliant, oppositional, and aggressive behaviors are among the most commonly referred for professional help. (Netherton, Holmes, & Walker, 1999, p. 118) As clinicians, the question isn’t if we will run into it, it’s more of a question of when… and so I consider ODD and CD, along with ADHD, to be among the most important and clinically significant studies we will likely undertake.

Complaints about ODD/CD children include annoying or aversive interpersonal behaviors (e.g., recurrent yelling, temper tantrums, impulsivity, excessive motor activity, lying, stealing), noncompliance with authority figures, defiance of social norms, and physically aggressive behaviors (e.g., hitting, fighting). (Netherton et al., 1999, p. 118) They are more aggressive, less empathetic, and more deficient in social-problem-skills, and they tend to misperceive the social environment. (Netherton et al., 1999, p. 119) In my experience, all of the above apply, and more. I have witnessed or seen presentations that coexist with ADHD, major depression, low self-esteem, and alcohol/substance abuse. Although my experience in a clinical setting is limited, I have rarely met individuals who exhibit ODD/CD traits that do not also exhibit symptoms of other pathologies. I believe the interplay of these comorbid pathologies has a compounding effect, intensifying the behaviors, thereby making them more difficult to diagnose and even more difficult to treat.

I was particularly drawn to the developmental course of the pathology, and I was wholly unaware that behaviors could begin to develop as early as infancy. Pre-reading, I was prone to implicate family interaction and environmental stress variables before genetic or temperamental. However, I think I will defer that judgment, as it would appear that heredity and temperamental inconsistencies (I almost used defects here, but it seemed too condemning?) play a significant role in the etiology. I was not at all surprised that the typical developmental course gets progressively more severe with age, especially as the kids being to identify with an oppositional and delinquent peer group. (Netherton et al., 1999, p. 121)

Am I the only one to notice that males always seem to have a higher prevalence of pathology? Aside from Rett’s Disorder, which is exclusively dedicated to females, males are almost always more likely to exhibit pathological behavior. I think it’s a conspiracy.

I understood, appreciated, and agreed with the statement that “the assessment process should strive to accurately understand the child’s behavioral and emotional functioning across time and multiple settings, as well as the contexts in which the child normally functions.” (Netherton et al., 1999, p. 124) I especially appreciate the last part of the statement, and I think it is important to recognize and appreciate situations where the child does accelerate. I think that’s a key part of the assessment that was under addressed in the text, as it gives us the opportunity to demonstrate the child (during the course of the interview) that they do, indeed, “have it in them.”

Custodial parents may harbor some psychopathology (e.g., anti-social behavior, alcohol abuse, depression) that might help to maintain the child’s problems and impede treatment efforts if not also addressed. (Netherton et al., 1999, p. 125) It would suffice to say that is pretty consistent with my experience. Matter of fact, “might” implies it happens less frequently than we are probably aware. Parent Management Training (PMT) looks like an ingenious intervention if the parents are willing, I wasn’t aware there was such a thing. I wouldn’t rule out individual or group therapy as a possible outlet as well, depending on the situation.

“Treatment professionals recognize the chronic nature of the difficulties which these children experience and follow the child and the family over the long run, similar to medical follow-up of an individual with a chronic illness.” (Netherton et al., 1999, p. 133) Simply because we are able to mitigate and subsequently resolve the immediate and pressing issues surrounding the precipitating event, doesn’t necessarily mean that we have really solved the problem. Inevitably there will be underlying systemic issues in the family structure, or adjunct issues that we can continue to address that will help prevent recurrence of disruptive behaviors. I really like this proactive approach, and I think it’s imperative that we continue to impress on families that we should attempt to “get ahead” and proactively address potential issues.

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Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.