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W H AT W E K N O W
ADHD and Coexisting
Conditions: Disruptive
Behavior Disorders
Attention-deficit/hyperactivity disorder (ADHD)
is a common neurobiological condition affecting 5-8 percent of school age children1,2,3,4,5,6,7 with symptoms persisting into adulthood in as many as 60 percent of cases (i.e. approximately 4% of adults). 8,9 In addition, approximately two thirds of children with ADHD have at least one other coexisting condition.10As can be seen, any disorder can coexist with ADHD, but certain disorders such as the disruptive behavior disorders seem to occur more commonly.11This What We Know Sheet deals with the common disruptive behavior disorders oppositional defiant disorder (ODD) and conduct disorder (CD). Having one of these coexisting Disruptive Behavior Disorders (ODD/CD) can not only complicate the diagnosis and treatment but also worsen the prognosis. Even though many children with ADHD ultimately adjust, some (especial y those with an associated conduct or oppositional defiant disorder) are more likely to drop out of school, have fewer years of overall education, have less job satisfaction and fare less well as adults.12 Early diagnosis and treatment of these conditions is by far the best defense against these poorer www.help4adhd.org 1-800-233-4050
HOW ArE COExisTiNg CONDiTiONs
assessed with a view to exploring the possibility that iDENTifiED?
ODD or CD may be present in addition to ADHD.
As the diagnosis of ADHD is being considered, the Disruptive behavior disorders include two similar
clinician or mental health professional must also disorders: oppositional defiant disorder (ODD) and determine whether there are any other psychiatric conduct disorder (CD). Common symptoms occurring disorders affecting the child that could be responsible for in children with these disorders include: defiance of presenting symptoms. Often, the symptoms of ADHD authority figures, angry outbursts, and other antisocial may overlap with other disorders. The challenge for the behaviors such as lying and stealing. It is felt that the clinician is to discern whether a symptom belongs to difference between oppositional defiant disorder and ADHD, to a different disorder, or to both disorders at the conduct disorder is in the severity of symptoms and that same time. For some children, the overlap of symptoms they may lie on a continuum often with a developmental among the various disorders makes multiple diagnoses progression from ODD to CD with increasing age.13 possible at the time of initial presentation. In some cases, another condition may arise after the diagnosis of Oppositional defiant disorder (ODD) refers to a
ADHD, necessitating continued monitoring by a trained recurrent pattern of negative, defiant, disobedient and professional even after the first diagnosis is made.
hostile behavior toward authority figures lasting at least six months. To be diagnosed with ODD four (or more) of the following symptoms must be present: • often loses temper “ Children and adolescents with
ADHD and CD often have more
• often actively defies or refuses to comply with adults’ difficult lives and poorer outcomes
• often blames others for his or her mistakes or than children with ADHD alone.”
• is often touchy or easily annoyed by others Using a combination of symptom questionnaires and interviews with the child, the parents and significant These behaviors must be exhibited more frequently others, the clinician determines if the child exhibits the than in other children of the same age and must characteristic symptoms of a disorder. In addition to cause significant impairment in social, academic or listing the symptoms, the clinician will ask when the occupational functioning to warrant the diagnosis.14 symptoms began, how long they have lasted, how severe they are, how they affect day-to-day functioning, as well Conduct disorder (CD) involves more serious behaviors
as whether or not other family members have had these including aggression toward people or animals, symptoms. As a result of this questioning, the clinician destruction of property, lying, stealing and skipping is able to determine if a child meets the criteria for school. The behaviors associated with CD are often diagnosis of ADHD and/or another disorder. described as delinquency. Children exhibiting these behaviors should receive a comprehensive evaluation.15 The diagnosis and treatment of ADHD are discussed Children and adolescents with ADHD and CD often extensively in What We Know #1:The Disorder Named have more difficult lives and poorer outcomes than ADHD AND DisrupTivE BEHAviOr
iNCiDENCE Of ADHD AND ODD Or CD
DisOrDErs
Approximately one-third to one-half of all children The high co-occurrence of ADHD with disruptive with ADHD may have coexisting oppositional defiant behavior disorders necessitates that all children with disorder (ODD). These children are often disobedient ADHD symptoms and disruptive behaviors need to be and have outbursts of temper. The rate of children What We KnoW 5B ADHD AnD Coexisting ConDitions: Disruptive BeHAvior DisorDers 2
meeting full diagnostic criteria for ODD is similar across behavioral support in the school can make a difference all ages. Males have a greater incidence of and parents should not hesitate to ask for assistance. ADHD and ODD, as do children of divorced parents and mothers with low socioeconomic status. Children with the ADHD combined subtype seem to be more likely to Parent Training (PT): Parent training has been shown
to be effective for treating oppositional and defiant In some cases, children with ADHD may eventual y behaviors. Standardized parent training programs are develop conduct disorder (CD), a more serious pattern short-term interventions that teach parents specialized strategies including positive attending, ignoring, in 25 percent of children and 45 percent of adolescents the effective use of rewards and punishments, token economies, and time out to address clinical y significant 19 CD is more commonly seen in boys than girls, and increases in prevalence with age. Children behavior problems.23 Such training programs may with ADHD who also meet diagnostic criteria for CD are twice as likely to have difficulty reading, and are at Severe cases of CD may require multisystemic therapy, greater risk for social and emotional problems. 20 Non- an intensive family- and community-based treatment aggressive conduct problems increase with age, while that addresses the multiple causes of serious antisocial behavior in youth. This approach is very comprehensive and demanding. The therapist using such an approach must possess access to developmental and clinical risKs Of HAviNg ADHD AND A
expertise. These intervention services are delivered in DisrupTivE BEHAviOr DisOrDEr
a variety of settings (i.e., home, school, peer groups) Children with ADHD and CD are often at higher risk as needed. Academic and school-based problems are for contact with the police and the court system than included and some therapists work directly with an children with ADHD alone. These children frequently lie or steal and tend to disregard the welfare of others. In Parent-child interaction therapy is a treatment that addition, they risk getting into serious trouble at school teaches parents to strengthen the relationship with their or with the police. The risk for legal troubles may be child and to learn behavior management techniques. It mostly attributable to the symptoms of CD rather than has been found to be effective in the long term for young children with ODD and ADHD. Three to six years after Disruptive behavior disorders and untreated ADHD have been found to lead to an increased risk of “.early recognition and treatment
disruptive behaviors disorders and ADHD are more of both the ADHD and disruptive
likely to be aggressive and hostile in their interactions with others, and to be arrested. It has also been behaviors in children is essential.”
suggested that the greater impulsivity associated with the ADHD may cause greater antisocial behavior and its consequences.22 Thus, early recognition and treatment of both the ADHD and disruptive behaviors in children is treatment, the mothers of children with these disorders reported that the changes in their children’s behavior and their own feelings of control had lasted. Mothers’ reports of disruptive behavior decreased with time after TrEATmENT Of ADHD AND DisrupTivE
BEHAviOr DisOrDErs
Collaborative Problem Solving (CPS): Another
All children with symptoms of ADHD and ODD/ technique that seems to be promising for children with CD need to be assessed so that both types of problem ADHD and ODD is col aborative problem-solving behaviors can be treated. These children are difficult to (CPS).26 CPS is a treatment that teaches difficult children live with and parents need to understand that they do and adolescents how to handle frustration and learn to not need to deal with their ADHD and ODD/CD child be more flexible and adaptable. Parents and children alone. Interventions such as parent training at home and What We KnoW 5B ADHD AnD Coexisting ConDitions: Disruptive BeHAvior DisorDers 3
learn to brainstorm for possible solutions, negotiate, attentive, but less antisocial and aggressive. ADHD make decisions, and implement solutions that are medications are often effective treatments for aggressive acceptable to both. They learn to resolve disagreements or antisocial behavior in patients with ADHD and certainly play a role in any treatment program. (See Family Therapy: Often a child’s behavior can have an
What We Know #3: Managing Medication in Children effect on the whole family. Parents of children with and Adolescents with ADHD for more information.) ADHD often report marital difficulties. Mothers may be In addition to using stimulant medications alone, more depressed and siblings may also develop behavior medication combinations to reduce behavioral and problems. Family therapy is critical to helping a family conduct symptoms associated with attention-deficit/ address these issues and cope with the realities of having hyperactivity disorder appear to be very effective. a child with ADHD and disruptive behaviors. Seeking In several studies, this treatment combination was out a counselor or family therapist in your neighborhood reported to be well tolerated and unwanted effects were can help the entire family address these issues.
sCHOOl iNTErvENTiONs
WHAT CAN A pArENT DO?
School-wide Positive Behavioral Supports: In addition
To increase the chance for a successful future and to the environment at home, the school can have a to discourage delinquent behaviors in children with significant impact on a child’s behavior patterns. Many ADHD, diagnosis and intervention is extremely school systems now have programs in place to provide important. It is essential for parents to provide structure school-wide positive behavioral supports. The aim and reinforce appropriate behavior. In addition, a of these programs is to foster both successful social positive behavior management plan to lessen anti-social behavior and academic gains for all students. These behavior is important. Parents should discuss their programs consist of: (1) clear, consistent consequences child’s behavioral symptoms with the pediatrician for inappropriate behaviors; (2) positive contingencies for appropriate behaviors; and (3) team-based services or family practitioner and seek a referral to a mental for those students with the more extreme behavioral health professional who can suggest effective parenting Tutoring: Children’s ADHD symptoms, as well
In addition, parents should contact their child’s school as oppositional symptoms, have been found to be counselor or school psychologist to discuss possible significantly lower in one-on-one tutoring sessions than interventions to improve behaviors at school. Having the counselor or psychologist support the teacher in handling classroom behaviors often results in significant Classroom Management: Providing appropriate
behavioral changes and decreases the incidence of instructional supports in the classroom can also lessen expulsion. Consistent behavior management at home, disruptive behavior. These include: creating an accepting school and elsewhere needs to be enforced.
and supportive classroom climate, promoting social and emotional skil s, establishing clear rules and procedures, monitoring child behavior, utilizing rewards effectively, fOr mOrE iNfOrmATiON AND furTHEr
responding to mild problem behaviors consistently and effectively managing anger or aggressive behavior.
Barkley, Russel . (2000) Taking charge of AD/HD: The complete, authoritative guide for parents (revised edition). New York, NY: Guilford Press. This book was written for parents and others mEDiCATiON
who want to know more about ADHD and its management. The book covers the disorder, the evaluation/assessment Overall results from several clinical studies indicate process, managing home and school and the use of medication.
that medications used for the treatment of ADHD Barkley, Russel . (1998). Your defiant child: 8 steps to better (stimulants as well as non-stimulants) remain an behavior. New York, NY: Guilford Press. This book is divided important component in the treatment of ADHD and into two parts -- “Getting to Know Your Defiant Child” and coexisting ODD/CD.28,29 Children with these disorders “Getting Along with Your Defiant Child.” Part two contains an treated with these medications were not only more eight-step parenting program built on consistency. What We KnoW 5B ADHD AnD Coexisting ConDitions: Disruptive BeHAvior DisorDers 4
Clark, Lynn. (1996) SOS! Help for parents. Berkeley, CA: avoid the talk-persuade-argue-yell-hit syndrome. Parents Press. This book helps parents learn methods for Shure, Myrna. (1996) Raising a Thinking Child: Help your young helping children to improve their behavior and techniques for child to resolve everyday conflicts and get along with others. aiding a variety of child personalities, from the stubborn and New York, NY: Pocket. This book provides steps that parents willful child to time-out basics. It focuses on the basic skil s of can follow in teaching young children to solve problems time-out and how parents can use these techniques to further a and resolve daily conflicts. The book includes dialogues for handling specific situations, games and activities, and Forgatch, Marion S. and Gerald R. Patterson. (2005) Parents and adolescents living together: Family problem solving. Champaign, IL: Research Press. This book shows parents how to improve their communication and problem-solving rEfErENCEs
skil s, hold family meetings and get the whole family involved 1. American Psychiatric Association (2000). Diagnostic and in solving problems. It explains how parents can teach their statistical manual of mental disorders: DSM IV (4th ed., text, teenaged children to be responsible about schoolwork, sexual revision), Washington, D.C.: American Psychiatric Association.
2. Mayo Clinic. (2002). How Common is Attention-Deficit/ Goldstein, Sam; Robert Brooks and Sharon K. Weiss. (2004) Hyperactivity Disorder? Archives of Pediatrics and Adolescent Angry children, worried parents: Seven steps to help families manage anger. Plantation, FL: Specialty Press. This book helps parents cope with anger in their children. It presents the 3. Mayo Clinic (2001). Utilization and Costs of Medical Care following seven steps to help children learn to manage anger: for Children and Adolescents with and without Attention- (1) understand why children become angry; (2) determine Deficit/Hyperactivity Disorder. Journal of the American Medical when your child needs help; (3) help the child become an active participant in the process; (4) use strategies to manage and 4. Surgeon General of the United States (1999). Mental express anger; (5) develop and implement a daily management Health: A Report of the Surgeon General. Rockville, MD: U.S. plan; (6) assess and solve problems; and (7) instill a resilient Department of Health and Human Services.
5. American Academy of Pediatrics (2000). Clinical practice Greene, Ross W. (1998). The explosive child: A new approach guidelines: Diagnosis and evaluation of the child with for understanding and parenting easily frustrated, chronical y attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158- inflexible children. New York, NY: HarperCollins. This book discusses explosive-inflexible behavior in children, which may be associated with ADHD, oppositional defiant disorder, 6. Centers for Disease Control and Prevention (2003). obsessive-compulsive disorder, or other psychiatric disorders. Prevalence of diagnosis and medication treatment for The author argues that behavioral techniques do not work with attention-deficit/hyperactivity disorder. Morbidity and a small subset of children, who simply lack the skil s to improve Mortality Weekly Report 54: 842-847.
their behavior. He advocates using positive, less adversarial 7. Froehlich, T.E., Lanphear, B.P., Epstein, J.N., et al. Prevalence, interactions, and looking for ways to anticipate, prevent and recognition, and treatment of attention-deficit/hyperactivity re-direct explosive behavior when possible. disorder in a national sample of US children. Archives of Patterson, Gerald Roy. (1977) Living with children: New Pediatric and Adolescent Medicine (2007), 161:857-864.
methods for parents and teachers. Champaign, IL: Research 8. Faraone, S.V., Biederman, J., & Mick, E. (2006) The age- Press. In short, easy-to-read chapters, this book explains dependent decline of attention-deficit hyperactivity disorder: how to change the way your child behaves by using behavior A meta-analysis of follow-up studies. Psychol Med (2006), 36: modification techniques. It describes how to use positive reinforcement to stop common problems such as bedwetting, 9. Kessler, R.C., Adler, L., Barkley, R., Biederman, J., et al. The prevalence and correlates of adult ADHD in the United States: Patterson, Gerald Roy and Marion S. Forgatch. (1987) Parents Results from the National Comorbidity Survey Replication. and adolescents working together, Part I: The basics. Eugene, Am Journal of Psychiatry (2006), 163:724-732.
OR: Castalia Publishing. This book offers parents behavior 10. Biederman, J.; Faraone, S.V.; & Lapey, K. (1992). modification guidelines they can use with teenagers to foster Comorbidity of diagnosis in attention-deficit hyperactivity a good relationship and prevent battles. It explains how to use disorder. In G. Weiss (Ed.), Attention-deficit hyperactivity requests that work, how to monitor and track behavior, how to disorder, child & adolescent clinics of North America. set up point charts and how to discipline effectively. Phelan, Tom. (2003) 1-2-3 Magic: Effective discipline for 11. Adesman A, (2003). A diagnosis of AD/HD? Don’t overlook children 2-12 (third edition). Glen El yn, IL: ParentMagic the probability of comorbidity! Contemporary Pediatrics 20 Inc. The author presents three steps for disciplining children: controlling obnoxious behavior, encouraging good behavior and strengthening the relationship with the child. The author 12. Murphy KR; Barkley RA; & Bush T. (2002). Yound adults also explains how to manage the six kinds of testing and with attention deficit hyperactivity disorder: subtype differenes manipulation, how to handle misbehavior in public and how to in comorbidity, educational and clinical history. Journal of What We KnoW 5B ADHD AnD Coexisting ConDitions: Disruptive BeHAvior DisorDers 5
Nervous and Mental Disorders, 190(3): 147-157.
sypmptoms of attention defecity hyperactivity disorder and 13. Loeber R., et al. 1993. Journal of Abnormal Child Psychology, oppositional defiant disorder during individual tutoring as compared with classroom instruction. Psychology Rep, 91(1): 14. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: DSM IV (4th ed., text, 28. Pliszka, S.R. (2003).Psychiatric comorbidities in children revision), Washington, D.C.: American Psychiatric Association with attention deficit hyperactivity disorder: implications for management. Pediatric Drugs, 5: 741-750.
15. Maughan B; Rowe R; Messer J, et al. (2004). Conduct disorder and oppositional defiant disorder in a national sample: 29. Newcorn, J.H.; Spencer, T. J.; Biederman, J., et al. (2005).
developmental epidemiology. Journal of Child Psychology and Atomoxetine Treatment in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder and Comorbid Oppositional Defiant Disorder. Journal of the American 16. Harada, Y.; Yamazaki, T.; & Saitoh, K. (2002). Psychosocial Academy of Child Adolescent Psychiatry, 44(3) p240-248. problems in attention-deficit hyperactivity disorder with oppositional defiant disorder. Psychiatry and Clinical 30 Hazel , P.L. & Stuart, J.E. (2003). A randomized controlled trial of clonodine added to psychostimulant medication for hyperactive and aggressive children. Journal American 17. Kadesjo C; Hagglof B; Kadesjo B, et al. (2003). Attention Academy of Child and Adolescent Psychiatry, 42(8): 886-894.
deficit-hyperactivy-disorder with and without oppositional defiant disorders in 3 to 7-year-old children. Developmental 31 Conner, D.F.; Barkley, R.A.; & Davis, H.T. (2000) A pilot Medicine and Child Neurology, 45(10) 693-699.
study of methylphenidate, clonodine, or the combination in AD/HD comorbid with aggressive oppositional defiant or 18. Lahey, B. B.; McBurnett, K.; & Loeber, R. (2000). Are conduct disorder. Clinical Pediatrics, 39(1): 15-25.
attention-deficit/hyperactivity disorder and oppositional defiant disorder developmental precursors to conduct disorder? The information provided in this fact sheet was supported by In A. J. Sameroff, M. Lewis, & S. M. Miller (Eds.), Handbook of Grant/Cooperative Agreement Number 5U38DD000335-05 from developmental psychopathology (2nd ed.) (pp. 431-446.). New the Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of the authors and do not 19. NRC on ADHD (2004). What We Know #5: ADHD and Co- necessarily represent the official views of CDC. This fact sheet Existing Conditions. Landover, MD: National Resource Center was approved by CHADD’s Professional Advisory Board in 2005. 20. Pliszka, S.R. (2003). Psychiatric comorbidities in children 2005 Children and Adults with Attention-Deficit/ with attention hyperactivity disorder: implications for management. Paediatric Drugs, 5, 741-750.
21. Bukstein, O.G. (2000). Disprutive behavior disorders and substance use disorders in adolescents. Journal of Psychoactive Permission is granted to photocopy and freely distribute this What We Know sheet for non-commercial, 22. Murphy, K.R.; Barkley, R.A.; & Bush, T. (2002).Young educational purposes only, provided that this document adults with attention deficit hyperactivity disorder: subtype is reproduced in its entirety, including the CHADD differences in comorbidity, educational, and clinical history. Journal of Nervous and Mental Disorders, 190(3,): 147-157.
and NRC names, logos, and all contact information. Permission to distribute this material electronical y 23. Farley, S.E.; Adams, J.S.; & Lutton, M.E., et al. (2005). What are effective treatments for oppositional and defiant behaviors without express written permission is denied.
in preadolescents? Journal of Family Practice, 54(2): 162-165. 24. Henggeler, S.W., Rodick, J.D., Bordum, C.M., Hanson, For further information about aDhD or ChaDD, please C.L.,Watson, S.M., & Urey, J.R. (1986). Multisystemic treatment of juvenile offenders: Effects on adolescent behavior and family national resource Center on ADHD
interactions. Developmental Psychology, 22, 132-141. Children and Adults with Attention-Deficit/
25. Hood, K.K. & Eyberg, S.M. (2003). Outcomes of parent- Hyperactivity Disorder
child interaction therapy: mothers; reports of maintenance three to six years after treatment. Journal of Clinical Child and Adolescent Psychology, 32(3): 419-429.
26. Greene, R.W.; Ablon, J.S.; Goring, J.C., et al. (2004).
Effectiveness of col aborative problem with solving in effectively dysregulated children with oppositional-defiant disorder: initial findings. Journal of Consulting and Clinical 27. Stayhorn, J.M. & Bickel, D.D. (2002).Reduction in children’s What We KnoW 5B ADHD AnD Coexisting ConDitions: Disruptive BeHAvior DisorDers 6

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