Discussion Project: ADHD Diagnosis

15 disorders of childhood and adolescence (neurodevelopmental disorders)

learning objectives 15

·  15.1 How does maladaptive behavior appear in different life periods?

·  15.2 What are the common disorders of childhood?

·  15.3 Do anxiety and depression appear in children and adolescents?

·  15.4 What are some specific disorders that occur in childhood?

·  15.5 What are intellectual disabilities?

·  15.6 How can we plan better programs to help children and adolescents?

A Case of Adolescent Depression and Attempted Suicide Emily is 15-year-old girl from a middle-class Caucasian background who had a history of depression during her childhood. She had periods of low mood, poor self-esteem, and social withdrawal. She also had symptoms of anxiety and was very reluctant to leave her home. During her year in the seventh grade, she became so fearful of going to school that she missed so many days she had to repeat the grade. She currently is in the eighth grade and has, to this point, missed a great deal of school. Her family became very concerned over Emily’s low mood and isolation, so they enrolled her in an out-patient treatment program for depression, anxiety episodes, and eating disorders. Her depression continued, and she became more isolated, lonely, and depressed and would not leave her room even for meals. One day her grandmother found her in their car in the garage with the engine running in an effort to end her life. Emily was admitted into an inpatient treatment program following her serious suicide attempt. Discussion Project: ADHD Diagnosis

There is a history of psychiatric problems, particularly mood disorders, in her family. Her mother has been hospitalized on three occasions for depression. Her maternal grandfather, now deceased, was hospitalized at one time following a manic depressive episode.

In the early phases of her hospitalization, Emily underwent an extensive psychological and psychiatric evaluation. She was administered a battery of tests, including the Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A). She was cooperative with the evaluation and provided the assessment staff with sufficient information regarding her mood and attitudes to assist in developing a treatment program.

Emily showed many symptoms of a mood disorder in which both depression and anxiety were prominent features. The psychological evaluation indicated that she was depressed, anxious, and felt unable to deal with the school stress that her condition prompted. Moreover, her physical appearance and eating behavior suggested the strong likelihood of anorexia nervosa. Emily showed an extreme degree of social introversion on several measures and acknowledged her reticence at engaging in social interactions. The assessment psychologist concluded that her personality characteristics of social withdrawal, isolation, and difficult interpersonal relationships would likely result in her having problems in establishing a therapeutic relationship. Her treatment program involved supportive cognitive therapy along with antidepressant medication.

Although she endorsed a broad range of anxiety symptoms, in her testing and in the intake interview she endorsed few items regarding suicidal ideation. This was not sufficient evidence to support a conclusion that she was at less risk for suicide; however, it could simply reflect her unwillingness to openly discuss her recent attempt. Her past behavior and low mood indicated a need to consider the possibility of further suicide attempts.

She remained in inpatient treatment for 3 weeks and was discharged with the summary that she had shown substantial improvement. She was, however, referred for further psychological treatment on an outpatient basis.

Source: Adapted from Williams & Butcher,  2011 , pp. 151–63.

Until the twentieth century, little account was taken of the special characteristics of psychopathology in children; maladaptive patterns considered relatively specific to childhood, such as autism, received virtually no attention at all. Only since the advent of the mental health movement and the availability of child guidance facilities at the beginning of the twentieth century have marked strides been made in assessing, treating, and understanding the maladaptive behavior patterns of children and adolescents. Discussion Project: ADHD Diagnosis

The problems of childhood were initially seen simply as downward extensions of adult-oriented diagnoses. The prevailing view was one of children as “miniature adults.” But this view failed to recognize special problems, such as those associated with the developmental changes that normally take place in childhood or adolescence. Only relatively recently have clinicians come to realize that they cannot fully understand childhood disorders without taking these developmental processes into account. Today, even though great progress has been made in providing treatment for disturbed children, facilities are still inadequate to the task, and most children with mental health problems do not receive psychological attention.

The number of children affected by psychological problems is considerable. Research studies in several countries have provided estimates of childhood disorders. Roberts, Roberts, et al. ( 2007 ) found that 17.1 percent of adolescents in large metropolitan areas of the United States meet the criteria for one or more DSM diagnoses. Verhulst ( 1995 ) conducted an evaluation of the overall prevalence of childhood disorder based on 49 studies involving over 240,000 children across many countries and found the average rate to be 12.3 percent. In most studies, maladjustment is found more commonly among boys than among girls; however, for some diagnostic problems, such as eating disorders (see  Chapter 8 ), rates are higher for girls than for boys. The most prevalent disorders are attention-deficit/hyperactivity disorder (ADHD) (Ryan-Krause et al.,  2010 ) and separation anxiety disorders (Cartwright-Hatton et al.,  2006 ). Some subgroups of the population—for example, Native Americans—tend to have higher rates of mental disorders. One study reported that 23 percent of the Native American children rated in the sample met criteria for 1 of the 11 mental disorders in the survey and 9 percent met criteria for 2 or more of the disorders (Whitbeck et al.,  2006 ).

Maladaptive Behavior in Different Life Periods

Several behaviors that characterize maladjustment or emotional disturbance are relatively common in childhood. Because of the manner in which personality develops, the various steps in growth and development, and the differing stressors people face in childhood, adolescence, and adulthood, we would expect to find some differences in maladaptive behavior in these periods. The fields of developmental science (Hetherington,  1998 ) and, more specifically,  developmental psychopathology  (Kim-Cohen,  2007 ) are devoted to studying the origins and course of individual maladaptation in the context of normal growth processes.

It is important to view a child’s behavior in the context of normal childhood development (Silk et al.,  2000 ). We cannot consider a child’s behavior abnormal without determining whether the behavior in question is appropriate for the child’s age. For example, temper tantrums and eating inedible objects might be viewed as abnormal behavior at age 10 but not at age 2. Despite the somewhat distinctive characteristics of childhood disturbances at different ages, there is no sharp line of demarcation between the maladaptive behavior patterns of childhood and those of adolescence, or between those of adolescence and those of adulthood. Thus, although our focus in this chapter will be on the behavior disorders of children and adolescents, we will find some inevitable carryover into later life periods.

Varying Clinical Pictures

The clinical picture of childhood disorders tends to be distinct from the clinical picture of disorders in other life periods. Some of the emotional disturbances of childhood may be relatively short lived and less specific than those occurring in adulthood. However, some childhood disorders severely affect future development. One study found that individuals who had been hospitalized as child psychiatric patients (between the ages of 5 and 17) died early in life due to unnatural causes (about twice the rate of the general population) when followed up from 4 to 15 years later (Kuperman et al.,  1988 ). The suicide risk among some disturbed adolescents is long-lasting and requires careful follow-up and attention (Fortune et al.,  2007 ). Suicidal thoughts are not uncommon in children. Riesch and colleagues ( 2008 ) report that 18 percent of sixth graders have thoughts of killing themselves. Two other recent studies have reported rates for children under age 15. Dervic, Brent, and Oquendo ( 2008 ) report that international suicide rates are 3.1 per million. Hawton and Harriss ( 2008 ) report that the long-term risk of suicide is 1.1 percent, with girls more likely than boys to commit suicide. Both studies report that difficult family relationships are the leading cause of suicidal behavior. Being bullied by another child is another factor that has been found to be associated with risk of suicide (Rivers & Noret,  2010 ).

Special Psychological Vulnerabilities of Young Children

Young children are especially vulnerable to psychological problems (Ingram & Price,  2001 ). In evaluating the presence or extent of mental health problems in children and adolescents, one needs to consider the following:

·  • They do not have as complex and realistic a view of themselves and their world as they will have later; they have less self- understanding; and they have not yet developed a stable sense of identity or a clear understanding of what is expected of them and what resources they might have to deal with problems.

·  • Immediately perceived threats are tempered less by considerations of the past or future and thus tend to be seen as disproportionately important. As a result, children often have more difficulty than adults in coping with stressful events (Mash & Barkley,  2006 ). For example, children are at risk for posttraumatic stress disorder after a disaster, especially if the family atmosphere is troubled—a circumstance that adds additional stress to the problems resulting from the natural disaster (Menaghan,  2010 ).

·  • Children’s limited perspectives, as might be expected, lead them to use unrealistic concepts to explain events. For young children, suicide or violence against another person may be undertaken without any real understanding of the finality of death.

·  • Children also are more dependent on other people than are adults. Although in some ways this dependency serves as a buffer against other dangers because the adults around him or her might “protect” a child against stressors in the environment, it also makes the child highly vulnerable to experiences of rejection, disappointment, and failure if these adults, because of their own problems, ignore the child (Lengua,  2006 ).

·  • Children’s lack of experience in dealing with adversity can make manageable problems seem insurmountable (Scott et al.,  2010 ). On the other hand, although their inexperience and lack of self-sufficiency make them easily upset by problems that seem minor to the average adult, children typically recover more rapidly from their hurts.

The Classification of Childhood and Adolescent Disorders

Until the 1950s no formal, specific system was available for classifying the emotional or behavioral problems of children and adolescents. Kraepelin’s ( 1883 ) classic textbook on the classification of mental disorders did not include childhood disorders. In 1952, the first formal psychiatric nomenclature (DSM-I) was published, and childhood disorders were included. This system was quite limited and included only two childhood emotional disorders: childhood schizophrenia and adjustment reaction of childhood. In 1966, the Group for the Advancement of Psychiatry provided a classification system for children that was detailed and comprehensive. Thus, in the 1968 revision of the DSM (DSM-II), several additional categories were added. However, growing concern remained—both among clinicians attempting to diagnose and treat childhood problems and among researchers attempting to broaden our understanding of childhood psycho-pathology—that the then-current ways of viewing psychological disorders in children and adolescents were inappropriate and inaccurate for several reasons. The greatest problem was that the same classification system that had been developed for adults was used for childhood problems even though many childhood disorders, such as autism, learning disabilities, and school phobias, have no counterpart in adult psychopathology. The early systems also ignored the fact that in childhood disorders, environmental factors play an important part in the expression of symptoms—that is, symptoms are highly influenced by a family’s acceptance or rejection of the behavior. In addition, symptoms were not considered with respect to a child’s developmental level. Some of the problem behaviors might be considered age appropriate, and troubling behaviors might simply be behaviors that the child will eventually outgrow. In the most recent revision of the diagnostic and statistical manual (DSM-5), efforts were made to provide diagnostic classification that is consistent with current research and contemporary clinical practice. Discussion Project: ADHD Diagnosis

in review

·  • Define developmental psychopathology.

·  • Discuss the special psychological vulnerabilities of children.

Common Disorders of Childhood

At present the DSM-5 provides diagnoses for a large number of childhood and adolescent disorders or Neurodevelopmental Disorders. In addition, several disorders, involving intellectual disability (formerly referred to as mental retardation) are included. Space limitations do not allow us to explore fully the mental disorders of childhood and adolescence included in the DSM system, so we have selected several disorders to illustrate the broad range of problems that can occur in childhood and adolescence. Some of these disorders are more transient than many of the abnormal behavior patterns of adulthood discussed in earlier chapters—and also perhaps more amenable to treatment while others have a likelihood of persistence.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) , often referred to as hyperactivity, is characterized by difficulties that interfere with effective task-oriented behavior in children—particularly impulsivity, excessive or exaggerated motor activity, such as aimless or haphazard running or fidgeting, and difficulties in sustaining attention (Nigg et al.,  2005 ; see DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder). The diagnostic criteria for ADHD remained relatively unchanged for children and adolescents in DSM-5.

Children with ADHD are highly distractible and often fail to follow instructions or respond to demands placed on them (Wender,  2000 ). Perhaps as a result of their behavioral problems, children with ADHD are often lower in intelligence, usually about 7 to 15 IQ points below average (Barkley,  1997 ). Children with ADHD also tend to talk incessantly and to be socially intrusive and immature. Recent research has shown that many children with ADHD show deficits on neuropsychological testing that are related to poor academic functioning (Biederman et al.,  2004 )  Watch the Video Jimmy: Attention-Deficit/Hyperactivity Disorder on MyPsychLab .

Children with ADHD generally have many social problems because of their impulsivity and overactivity. Hyperactive children usually have great difficulty in getting along with their parents because they do not obey rules. Their behavior problems also result in their being viewed negatively by their peers (Hoza et al.,  2005 ). In general, however, hyperactive children are not anxious, even though their overactivity, restlessness, and distractibility are frequently interpreted as indications of anxiety. They usually do poorly in school and often show specific learning disabilities such as difficulties in reading or in learning other basic school subjects. Hyperactive children also pose behavior problems in the elementary grades. The case study on page 513 reveals a typical clinical picture.

The symptoms of ADHD are relatively common among children seen at mental health facilities in the United States, with from 3 to 7 percent reported in the DSM and 8 percent reported in a recent study in the United Kingdom (Alloway et al.,  2010 ). In fact, hyperactivity is the most frequently diagnosed mental health condition in children in the United States (Ryan-Krause et al.,  2010 ). The disorder occurs most frequently among preadolescent boys—it is six to nine times more prevalent among boys than among girls. ADHD occurs with the greatest frequency before age 8 and tends to become less frequent and to involve briefer episodes thereafter. ADHD has also been found to be comorbid with other disorders such as oppositional defiant disorder (ODD) (Staller,  2006 ), which we discuss later. Some residual effects, such as attention difficulties, may persist into adolescence or adulthood (Odell et al.,  1997 ). ADHD is found in other cultures (Bauermeister et al.,  2010 )—for example, one study of 1,573 children from 10 European countries reported that ADHD symptoms are similarly recognized across all countries studied and that the children are significantly impaired across a wide range of domains. Discussion Project: ADHD Diagnosis

DSM-5 criteria for: Attention-Deficit/Hyperactivity Disorder

·  A. A persistent pattern of inattention and/or hyperactivityimpulsivity that interferes with functioning or development, as characterized by (1) and/or (2):

·  1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

·  a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

·  b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

·  c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

·  d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

·  e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

·  f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

·  g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

·  h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

·  i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

·  2 Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

·  a. Often fidgets with or taps hands or feet or squirms in seat.

·  b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

·  c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)

·  d. Often unable to play or engage in leisure activities quietly.

·  e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

·  f. Often talks excessively.

·  g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).

·  h. Often has difficulty waiting his or her turn (e.g., while waiting in line).

·  i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

·  B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

·  C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

·  D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

·  E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

CAUSAL FACTORS IN ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

The cause or causes of ADHD in children have been much debated. It still remains unclear to what extent the disorder results from environmental or biological factors (Carr et al.,  2006 ; Hinshaw et al.,  2007 ), and recent research points to both genetic (Sharp et al.,  2009 ; Ilott et al.,  2010 ) and social environmental precursors (Hechtman,  1996 ). Many researchers believe that biological factors such as genetic inheritance will turn out to be important precursors to the development of ADHD (Durston,  2003 ). But firm conclusions about any biological basis for ADHD must await further research. Discussion Project: ADHD Diagnosis

Gina, a Student with Hyperactivity Gina was referred to a community clinic because of overactive, inattentive, and disruptive behavior. Her hyperactivity and uninhibited behavior caused problems for her teacher and for other students. She would impulsively hit other children, knock things off their desks, erase material on the blackboard, and damage books and other school property. She seemed to be in perpetual motion, talking, moving about, and darting from one area of the classroom to another. She demanded an inordinate amount of attention from her parents and her teacher, and she was intensely jealous of other children, including her own brother and sister. Despite her hyper-active behavior, inferior school performance, and other problems, she was considerably above average in intelligence. Nevertheless, she felt stupid and had a seriously devaluated self-image. Neurological tests revealed no significant organic brain disorder.

The search for psychological causes of ADHD has yielded similarly inconclusive results, although temperament and learning appear likely to be factors. One study suggested that family pathology, particularly parental personality, can be transmitted to children (Goos et al.,  2007 ), and another recent study found that prenatal alcohol exposure can increase the severity of problems in children with ADHD (Ware et al.,  2012 ). Currently, ADHD is considered to have multiple causes and effects (Hinshaw et al.,  1997 ). Whatever cause or causes are ultimately determined to be influential in ADHD, the mechanisms underlying the disorder need to be more clearly understood and explored. There is general agreement that processes operating in the brain are disinhibiting the child’s behavior (Nigg,  2001 ), and some research has found different EEG patterns occurring in children with ADHD than in children without ADHD (Barry et al.,  2003 ). At this time, however, theorists do not agree what those central nervous system processes are. Discussion Project: ADHD Diagnosis

TREATMENTS AND OUTCOMES

Although the hyperactive syndrome was first described more than 100 years ago, disagreement over the most effective methods of treatment continues, especially regarding the use of drugs to calm a child with ADHD. Yet this approach to treating children with ADHD has great appeal in the medical community; one survey (Runnheim et al.,  1996 ) found that 40 percent of junior high school children and 15 percent of high school children with emotional and behavioral problems and ADHD are prescribed medication, mostly  Ritalin  (methylphenidate), an amphetamine. In fact, school nurses administer more daily medication for ADHD than for any other chronic health problem.

Interestingly, research has shown that amphetamines have a quieting effect on children—just the opposite of what we would expect from their effects on adults. For children with ADHD, such stimulant medication decreases overactivity and distractibility and, at the same time, increases their alertness (Konrad et al.,  2004 ). As a result, they are often able to function much better at school (Hazell,  2007 ; Pelham et al.,  2002 ).

Fava ( 1997 ) concludes that Ritalin can often lower the amount of aggressiveness in children with ADHD. In fact, many children whose behavior has not been acceptable in regular classes can function and progress in a relatively normal manner when they use such a drug. In a 5-year follow-up study, Charach, Ickowicz, and Schachar ( 2004 ) reported that children with ADHD on medication showed greater improvement in teacher-reported symptoms than nontreated children. The possible side effects of Ritalin, however, are numerous: decreased blood flow to the brain, which can result in impaired thinking ability and memory loss; disruption of growth hormone, leading to suppression of growth in the body and brain of the child; insomnia; psychotic symptoms; and others. Although amphetamines do not cure ADHD, they have reduced the behavioral symptoms in about one-half to two-thirds of the cases in which medication appears warranted. Discussion Project: ADHD Diagnosis

Ritalin has been shown to be effective in the short-term treatment of ADHD (Goldstein,  2009 ; Spencer,  2004a ). There are newer variants of the drug, referred to as extended-release methylphenidate (Concerta), that have similar benefits but with available doses that may better suit an adolescent’s lifestyle (Mott & Leach,  2004 ; Spencer,  2004b ).

Three other medications for treating ADHD have received attention in recent years.  Pemoline  is chemically very different from Ritalin (Faigel & Heiligenstein,  1996 ); it exerts beneficial effects on classroom behavior by enhancing cognitive processing but has less adverse side effects (Bostic et al.,  2000 ; Pelham et al.,  2005 ).  Strattera  (atomoxetine), a noncontrolled treatment option that can be obtained readily, is an FDA-approved non-stimulant medication (FDA,  2002 ). This medication reduces the symptoms of ADHD (Friemoth,  2005 ), but its mode of operation is not well understood. The side effects for the drug are decreased appetite, nausea, vomiting, and fatigue. The development of jaundice has been reported, and the FDA ( 2004 ) has warned of the possibility of liver damage from using Strattera. Although Strattera has been shown to reduce some symptoms of ADHD, further research is needed to evaluate its effectiveness and potential side effects (Barton et al.,  2005 ). Another drug that reduces symptoms of impulsivity and hyperactivity in children with attention deficit/hyperactivity disorder is  Adderall . This medication is a combination of amphetamine and dextro-amphetamine; however, research has suggested that Adderall has no advantage or improvement in results over Ritalin or Strattera (Miller-Horn et al.,  2008 ). Discussion Project: ADHD Diagnosis

Although the short-term pharmacological effect of stimulants on the symptoms of hyperactive children is well established, their long-term effects are not well known (Safer,  1997a ). Carlson and Bunner ( 1993 ) reported that studies of achievement over long periods of time failed to show that the medication has beneficial effects. The pharmacological similarity of Ritalin and cocaine, for example, has caused some investigators to be concerned about its use in the treatment of ADHD (Volkow et al.,  1995 ). There have also been some reported recreational uses of Ritalin, particularly among college students. Kapner ( 2003 ) described several surveys in which Ritalin was reportedly abused on college campuses. In one survey, 16 percent of students at one university reported using Ritalin, and in another study 1.5 percent of the population surveyed reported using Ritalin for recreational purposes within the past 30 days. Some college students share the prescription medications of friends as a means of obtaining a “high” (Chutko et al.,  2010 ).

Some authorities prefer using psychological interventions in conjunction with medications (Mariani & Levin,  2007 ). The behavioral intervention techniques that have been developed for ADHD include selective reinforcement in the classroom (DuPaul et al.,  1998 ) and family therapy (Everett & Everett,  2001 ). Another effective approach to treating children with ADHD involves the use of behavior therapy techniques featuring positive reinforcement and the structuring of learning materials and tasks in a way that minimizes error and maximizes immediate feedback and success (Frazier & Merrill,  1998 ). An example is providing a boy with ADHD immediate praise for stopping to think through a task he has been assigned before he starts to do it. The use of behavioral treatment methods for ADHD has reportedly been quite successful, at least for short-term gains. Discussion Project: ADHD Diagnosis

The use of psychosocial treatment of ADHD has also shown positive results (Pelham & Fabiano,  2008 ; Corcoran,  2011 ). Van Lier and colleagues ( 2004 ) conducted a school-based behavioral intervention program using positive reinforcement aimed at preventing disruptive behavior in elementary school children. They found this program to be effective with children with ADHD with different levels of disorder but most effective with children at lower or intermediate levels.

It is important to recognize that gender differences, as noted above, are found in ADHD, with the disorder being more prominent among boys than girls and the symptoms appraised differently. Recent concerns have been expressed over the possibility that treatment of females with symptoms of ADHD might not be provided because they are more often diagnosed as “predominantly inattentive” than boys. Rucklidge ( 2010 ) points out that females are less likely to be referred to treatment than males with ADHD although treatments appear to be equally effective for both genders. She points out that future research should be attentive to gender differences in the disorder and further examine potential differences that might occur in treatment and outcomes. Discussion Project: ADHD Diagnosis

ADHD BEYOND ADOLESCENCE

A number of changes were made to the diagnostic criteria of ADHD in the development of DSM-5 in order to expand the diagnoses “across the life span.” Although the diagnostic criteria were not substantially changed for ADHD in DSM-5, some adjustments as to age level of the appearance of symptoms were modified to allow the diagnosis in adult years.

Some researchers have reported that many children with ADHD retain symptoms and behavior into early adulthood. Kessler, Adler, and colleagues ( 2006 ) reported a prevalence rate of 4.4 percent in adult patients. Many children with ADHD go on to have other psychological problems such as overly aggressive behavior or substance abuse in their late teens and early adulthood (Barkley et al.,  2004 ). For example, Carroll and Rounsaville ( 1993 ) found that 34.6 percent of treatment-seeking cocaine abusers in their study had met the criteria for ADHD when they were children. In a 30-year follow-up study of hyperactive boys with conduct problems, Satterfield and colleagues ( 2007 ) reported that such boys are at substantial increased risk for adult criminality. Biederman and colleagues ( 2010 ) conducted an 11-year follow-up study of girls with ADHD and found that girls with ADHD were at high risk for antisocial, addictive, mood, anxiety, and eating disorders. In another recent study, college students with ADHD have been shown to exhibit more on-the-job difficulties than peers without ADHD (Shifrin et al.,  2010 ). In a recent follow-up study of children with ADHD, Klein and colleagues ( 2012 ) reported that compared with peers without ADHD, those with ADHD displayed dysfunction in multiple domains as adults. Educational and occupational attainment was significantly compromised, leading to a relative economic disadvantage. Discussion Project: ADHD Diagnosis

More  longitudinal research  is clearly needed before we can conclude that children with ADHD go on to develop similar or other problems in adulthood. Mannuzza, Klein, and Moulton ( 2003 ) reported that estimates of the numbers of children with ADHD who will experience symptoms of ADHD in adulthood are likely to vary considerably. However, some of the research cited suggests that a significant percentage of adolescents continue to have problems in later life, and many continue to obtain treatment for ADHD (Doyle,  2006 ) or for other disorders such as major depression or bipolar disorder in their adult years (Klassen et al.,  2010 ).

research CLOSE-UP: Longitudinal Research

Longitudinal research involves studying and collecting baseline information on a specific group of interest (patients with a given disorder, high-risk children, etc.) and then following up with them at a future date (e.g., 1, 5, or even 20 years later) to determine the changes that have occurred over the intervening period. Discussion Project: ADHD Diagnosis

Disruptive, Impulse-Control, and Conduct Disorder

The next group of disorders involves a child’s or an adolescent’s relationship to social norms and rules of conduct. In both oppositional defiant disorder and conduct disorder, aggressive or antisocial behavior is the focus. As we will see, oppositional defiant disorder is usually apparent by about age 8, and conduct disorder tends to be seen by age 9. These disorders are closely linked (Thomas,  2010 ). However, it is important to distinguish between persistent antisocial acts—such as setting fires, where the rights of others are violated—and the less serious pranks often carried out by normal children and adolescents. Also, oppositional defiant disorder and conduct disorder involve misdeeds that may or may not be against the law;  juvenile delinquency  is the legal term used to refer to violations of the law committed by minors. (See the Unresolved Issues section at the end of this chapter.)

THE CLINICAL PICTURE IN OPPOSITIONAL DEFIANT DISORDER

An important precursor of the antisocial behavior seen in children who develop conduct disorder is often what is now called  oppositional defiant disorder (ODD)  and categorized under Disruptive, Impulse-Control, and Conduct Disorders in DSM-5. The criteria for ODD were changed in DSM-5 somewhat from the DSM-IV disorder. The ODD disorder is now grouped into three subtypes: angry/irritable mood, argumentative/defiant behavior and vindictiveness. Moreover, a severity rating has been included as an indicator of severity. The essential feature is a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months. This disorder usually begins by the age of 8, whereas full-blown conduct disorders typically begin from middle childhood through adolescence. The lifetime prevalence of ODD as reported in a national sample of adult respondents was relatively high: 11.2 percent for boys and 9.2 percent for girls (Nock et al.,  2007 ). Prospective studies have found a developmental sequence from oppositional defiant disorder to conduct disorder, with common risk factors for both conditions (Hinshaw,  1994 ). That is, virtually all cases of conduct disorder are preceded developmentally by oppositional defiant disorder, but not all children with oppositional defiant disorder go on to develop conduct disorder within a 3-year period (Lahey et al.,  2000 ). The risk factors for both include family discord, socioeconomic disadvantage, and antisocial behavior in the parents. Discussion Project: ADHD Diagnosis

DSM-5 criteria for: Conduct Disorder

·  A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

Aggression to People and Animals

·  1. Often bullies, threatens, or intimidates others.

·  2. Often initiates physical fights.

·  3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).

·  4. Has been physically cruel to people.

·  5. Has been physically cruel to animals.

·  6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).

·  7. Has forced someone into sexual activity.

Destruction of Property

·  8. Has deliberately engaged in fire setting with the intention of causing serious damage.

·  9. Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

·  10. Has broken into someone else’s house, building, or car.

·  11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).

·  12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious Violations of Rules

·  13. Often stays out at night despite parental prohibitions, beginning before age 13 years.

·  14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.

·  15. Is often truant from school, beginning before age 13 years.

·  B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

·  C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

THE CLINICAL PICTURE IN CONDUCT DISORDER

The essential symptomatic behavior in  conduct disorder  and ODD involves a persistent, repetitive violation of rules and a disregard for the rights of others and is essentially the same as in DSM-IV. Children with conduct disorder show a deficit in social behavior (Happe & Frith,  1996 ; see DSM Criteria for Conduct Disorder). In general, they manifest such characteristics as overt or covert hostility, disobedience, physical and verbal aggressiveness, quarrelsomeness, vengefulness, and destructiveness.

Lying, solitary stealing, and temper tantrums are common. Such children tend to be sexually uninhibited and inclined toward sexual aggressiveness. Some may engage in cruelty to animals (Becker et al.,  2004 ), bullying (Coolidge et al.,  2004 ), firesetting (Becker et al.,  2004 ; Slavkin & Fineman,  2000 ; Stickle & Blechman,  2002 ), vandalism, robbery, and even ho-micidal acts. Children and adolescents with conduct disorder are also frequently comorbid for other disorders such as substance-abuse disorder (Goldstein et al.,  2006 ) or depressive symptoms (O’Connor et al.,  1998 ).

Zoccolillo, Meyers, and Assiter ( 1997 ) found that conduct disorder is a risk factor for unwed pregnancy and substance abuse in teenage girls. Goldstein and colleagues ( 2006 ) report that early-onset conduct disorder is highly associated with later development of antisocial personality disorder (see  Chapter 8 ); Fergusson, Hor-wood, and Ridder ( 2007 ) and Yang and colleagues ( 2007 ) found that conduct disorder in childhood and adolescence is generally related to later substance use, abuse, and dependence. Discussion Project: ADHD Diagnosis