ADHD Weekly 2017-12-14

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If your child with ADHD has become more angry or aggressive, or refuses to comply with rules and requests, you may be concerned. These behaviors may signal the emergence of a Disruptive Behavior Disorder (DBD) such as Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD), which have high rates of co-occurrence with ADHD: From 45 percent to 84 percent of children with ADHD will meet full diagnostic criteria for ODD with or without CD. In studies of clinically referred adults with ADHD, 43 percent had a lifetime history of ODD. 

Because longitudinal studies have shown that DBD can lead to substance abuse or criminality, it is important to intervene early, before negative behaviors and attitudes―your child’s as well as yours and your family’s toward him or her―become firmly entrenched. The family tensions caused by a child’s disruptive behavior can create an escalating dynamic of negative behaviors; research has shown a strong link between maladaptive parenting and DBD.

What can you do?

A recent evidence-based review of treatment approaches for children with DBD conducted by researchers Jennifer Kaminski and Angelika Claussen of the Centers for Disease Control (CDC) identified six treatment method types for DBD, which in practice have been delivered under various conditions and combinations (“treatment families”). The review then ranks these treatment families into five levels of effectiveness, using a rigorous model for assessing evidence. 

The results of this review can help you and your doctor find appropriate treatment, because it identifies the types of treatment―and their characteristics―that are most effective, rather than focusing on name-brands that may not be found in your location.  

Understanding DBD 

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), children with ODD show a pattern of developmentally inappropriate, negative, aggressive, and defiant behavior. The signs of ODD include both emotional and behavioral symptoms that persist for six months or longer:

• Angry and irritable mood: Loses temper, is touchy or easily annoyed, or is angry and resentful
• Argumentative and defiant behavior: Argues with adults or people in authority, actively defies or refuses to comply with adults’ requests or rules, deliberately annoys people, or blames others for his/her mistakes or misbehavior
• Vindictiveness: Is spiteful or vindictive

CD occurs at a little later age than ODD. Approximately 30 percent of children diagnosed with ODD are later diagnosed with CD, which has a more targeted set of behaviors that consistently ignore the basic rights of others and violate social norms and rules. About 40 percent of children diagnosed with CD go on to have antisocial personality or other personality disorders.  The signs and symptoms of Conduct Disorder include serious, persistent behavior problems, such as:

• Aggression toward people and animals
• Destruction of property
• Deceitfulness
• Theft
• Serious violation of rules

Data from a 2007-2008 National Study of Children’s Health found the prevalence of DBD to be:

• 4.6 percent (2.8 million) of children had a history of DBD
• 3.5 percent (2.2 million) of children currently had a DBD

Those figures do not include undiagnosed cases. 

The most recent National Survey of Children’s Health data from 2016 have recently been publicly released, with publications from CDC and Health Resources and Services Administration expected soon, documenting the prevalence of behavioral disorders co-occurring with ADHD.

Types of treatment for disruptive behaviors

The six types of treatment approaches identified in the review, which can be conducted in different settings or conditions, are:

• Parent behavior therapy: In groups, individually with or without child participation, or via self-directed methods

• Teaches the parent(s) to be more effective behavioral reinforcers

• Focuses on strengthening the parent–child relationship so child is more motivated to behave in the way that the parent wants, and provides parents with more effective child behavior management strategies, e.g.:
• setting and clearly communicating developmentally appropriate limits and rules, 
• selecting and enforcing effective consequences for difficult behaviors, 
• preventing misbehavior
• Based on social learning principles: Applying or withholding positive reinforcement increases the child’s socially acceptable behaviors and decreases aggressive and oppositional behaviors.
• Relationship-enhancing strategies 
• providing the child with positive attention
• engaging in joint activities
• communication skills that convey to the child that the parent understands and wants to provide for the child’s needs
• Child behavior therapy: In groups or individually with or without parent participation
• Therapist interacts directly with the child to teach appropriate social skills. 
• Cognitive behavioral techniques to help the child 
• identify and understand their emotions and behavioral triggers, 
• evaluate ambiguous or threatening social situations, and 
• select appropriate behavioral responses. 
• Based on social learning principles and positive reinforcement
• Therapists may use modeling, role-plays, and behavior charts (with or without a token reward system) to teach and reinforce 
• child behaviors, 
• emotion regulation (e.g., relaxation, anger management), 
• perspective taking, 
• conflict resolution,
• how to make friends or enter peer group activities.
• Parent-focused therapy: In groups, individually with or without child participation
• "Focus on parents’ emotions, attitudes, or boundaries. 
• "Client-centered" or "Emotion-focused;" targets parents’: 
• emotion awareness and regulation, 
• attitudes and perceptions about their child 
• Addresses the underlying emotional or psychological issues within the parent, 
• which translates into more positive parenting and fewer child behavior problems.
• Specific skills taught could include: 
• emotion,
• regulation (e.g., relaxation, anger management), 
• perspective taking, 
• empathy, 
• knowledge of and attitudes about children’s behavior. 
• Some parent-focused programs target dysfunctional family processes and structures 
• reestablish boundaries that were either too rigid or too enmeshed. 
• Child-centered play therapy: In groups or individually
• Therapist goal is to provide: 
• close, supportive relationship for the child, 
• nondirective positive regard, warmth, and empathy,
• help for the child to express feelings, 
• a "safe" space for the child to explore and work through negative emotions. 
• Consistently provide nurturing relationship to naturally improve child’s behavior
• Nonbehavioral child therapy; typically doesn’t involve the parent(s) 
• Teacher Training
• Follows behavioral principles, focused on 
• classroom/group behavior management strategies 
• making the teacher a more effective reinforcer of children’s behavior. 
• Classroom behavior management strategies can include 
• visual cues to children about their behavior (e.g., token reward systems)
• preventive strategies (e.g., providing children with forewarnings before activity transitions). 
• May include help to teach social problem-solving skills directly to children.
• Family problem-solving training
• Engages the parent(s), child, and siblings in a problem-solving process to: 
• build the family’s ability to collaboratively resolve issues resulting from oppositional behavior. 
• Teaches the family how to:
• identify unsolved problems contributing to oppositional behavior, 
• prioritize which problems most need addressing, 
• collaboratively resolve the problems.

What works?

We interviewed Steve Lee, PhD, a professor in UCLA’s Department of Psychology, who participated with Dr. Kaminski in a webinar on DBD. Dr. Lee is a member of CHADD’s Professional Advisory Board with expertise in ADHD. Dr. Lee noted that the behavioral symptom link between ADHD and DBD lies in the lack of self-regulation, which in ADHD results from impaired executive function and in DBD enables disruptive behaviors. He concurred with Dr. Kaminski on the critical importance of acting early to get a professional diagnosis when symptoms of DBD appear and persist for six months or more. He emphasized the risk of maladaptive family dynamics developing if not addressed early, and that once those dynamics take hold, they tend to cascade or snowball. It is then harder and takes longer for therapy to reverse those behaviors.

The combination of ADHD co-occurring with DBD presents challenges for clinicians, both in diagnosis as well as in treatment. Dr. Lee notes that it’s a non-additive combination: A child who is distractible and disorganized has more difficulty learning new habits. He also notes another challenge: “Hostile attribution biases,” which develop from early experiences of maltreatment or victimization. Such bias causes the child to assume negative intentions in others’ actions, which then prompts aggressive reactions in the child.

The types of therapy addressed in the CDC review are critical for successfully treating disruptive behaviors. But Dr. Lee cautions, “It will get worse during therapy before it gets better.” That’s because your child won’t know how to deal with the new conditions in the family, even though those conditions are more positive. Your child has developed his behaviors, reactions and interactions within the context of prior family and parenting dynamics, and will not be able to immediately adjust to the new reality of positive parenting. He may “test” you, trying to recreate the prior conditions in which he understood what to expect. He’ll need time to develop trust in the “new normal,” to learn new ways of behaving, and to develop new expectations and understandings of others.

“Don’t pull out of therapy. If you stop therapy too early,” Dr. Lee said, “you will communicate to your child that he isn’t worth the effort, that he is a hopeless case.” 

More help for you:

The review by Dr. Kaminski and Dr. Claussen focused on children. For a review of evidence-based treatment for adolescent DBD, see Evidence-Based Psychosocial Treatments for Adolescents With Disruptive Behavior.

For a review of evidence-based treatments for ADHD, see Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder.

How have you been able to help your child who is struggling with behavioral issues?

Your child can sometimes be difficult, particularly when the impulsivity of his ADHD takes over. But lately he has been out of control—angry, irritable, argumentative, defiant. What’s going on, and what can you do about it?