Chapter 8: Behavioral Disorders in Children

General Considerations

Up to 20% of school-aged children in the United States have behavioral problems, at least half of which involve attention and/or hyperactivity difficulties. Attention Deficit Hyperactivity Disorder (ADHD) is the most common and well-studied of the childhood behavioral disorders.

Clinical Findings

Individuals diagnosed with ADHD are likely to experience significant difficulties with executive functioning, which impairs academic performance, social relationships, self-control, and memory. Brown (2005) outlines six executive function deficits that are observed in individuals diagnosed with ADHD: (1) organizing and prioritizing (difficulty getting started on tasks); (2) focusing and sustaining attention (easily distracted); (3) regulating alertness, sustaining effort (drowsiness); (4) managing frustration (low frustration tolerance or disproportionate emotional reactions); (5) working memory (difficulty retrieving information); and (6) self-regulation (difficulty inhibiting verbal and behavior responses).

There is no single diagnostic test or tool for ADHD. The diagnostic criteria included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) are the current basis for the identification of individuals with ADHD. There is rarely a need for extensive laboratory analysis, but screening for iron deficiency and thyroid dysfunction is reasonable.

The American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics (AAP), with input from members of the American Academy of Family Physicians, have formulated evidence-based practice guidelines to aid in the improvement of current diagnostic and treatment practices.

Differential Diagnosis

The diagnosis is made by parent interview, direct observation, and the use of standardized and scored behavioral checklists such as the Connors Parent and Teacher Rating Scales, Child Behavior Checklist (CBCL), Vanderbilt ADHD Diagnostic Parent and Teacher Scales, Achenbach, along with computerized tests (Gordon Diagnostic Testing, Connors Continuous Performance Task, and Test of Variables of Attention) measuring impulsivity and inattention that are specific for ADHD and should include input from both parents and teachers.

Complications

Attention deficit–hyperactivity disorder is often associated with other Axis I diagnoses. From 35% to 60% of referred ADHD children have oppositional defiant disorder (ODD), and 25-50% will develop conduct disorder (CD). Of these, 15–25% progress to antisocial personality disorder in adulthood. Of all referred ADHD children, 25–40% have a concurrent anxiety disorder. As many as 50% of referred children with ADHD eventually develop a mood disorder—most commonly depression, diagnosed in adolescence. The diagnosis of bipolar disease in childhood increases the risk of concurrent label of ADHD because of the overlap of behaviors. About half the children with Tourette syndrome have ADHD.

There is a definite association among ADHD, academic problems, and learning disabilities. Between 20% and 50% of children with ADHD have at least one type of learning disorder.

Treatment

A. Pharmacotherapy

1. Stimulants

Stimulant medications are the most frequently researched and the safest and most effective treatments for the symptoms of ADHD, but they are not a “cure.” The fact that stimulants are controlled substances (schedule II) with an abuse potential justifies the close scrutiny of their use. About 65% of children with ADHD show improvement in the core symptoms of hyperactivity, inattention, and impulsivity with their first trial of a stimulant, and ≤95% will respond when given appropriate trials of various stimulants. The management of these medications can be complex, and treatment failures may more often be the result of improper treatment strategies than effective medication.

Perhaps the most important step is the choice of medications. Stimulants most commonly used include methylphenidate (Ritalin, Concerta, Metadate CD, Ritalin LA, Methylphenidate ER, Daytrana), dexmethylphenidate (Focalin), dextroamphetamine (Dexedrine, Vyvanse), and mixed amphetamine salts (Adderall). In more recent years, novel drug delivery systems have been developed for stimulants and these formulations have become routine in clinical practice.

Absolute contraindications to the use of stimulants include concomitant use of monoamine oxidase (MAO) inhibitors, psychosis, glaucoma, underlying cardiac conditions, existing liver disorders, and a history of stimulant drug dependence. Adverse cardiovascular effects of stimulants have consistently documented mild increases in pulse and blood pressure of unclear clinical significance. Caution should be used in treating patients who have a family history of early cardiac death of arrhythmias or a personal history of structural abnormalities, palpitations, chest pain, and shortness of breath or syncope of unclear origin either before or during treatment with stimulants.

Because stimulants are Schedule II controlled substances, prescriptions with no refills are usually written monthly; however, several states allow 3-month prescriptions. Growth and vital signs should be checked and documented, and it is vital to monitor the medication effects and the child’s progress. Issues to address include: (1) adequacy and timing of the dosage, (2) compliance with the regimen, (3) changes in school or non-school-related activities that may affect medical therapy, and (4) maintenance of appropriate growth. An initial dropoff in weight gain may occur during titration phase, but over 2 years this reverses, resulting in no long-term sustained growth suppression from stimulant use. Drug holidays are no longer standard procedure, but parents may opt for their children to have periods off the medications to minimize potential unknown drug effects or to assess the continuing need for the medication.

2. Nonstimulants

Many nonstimulant medications are being used for ADHD, alone and in combination with neurostimulants. Nonstimulant agents are less widely studied and are summarized here to inform the physician about their use. They vary from the tricyclic antidepressants to α-agonists (Tenex, Intuniv and Clonidine, Kapvay) to the highly selective catecholamine reuptake inhibitor atomoxetine (Strattera). Nonstimulants are often used to treat both ADHD and comorbid states, and their effectiveness alone is generally less than that of the neurostimulants. Fear and misunderstanding about the effects of neurostimulants make these nonstimulant agents attractive to parents.

B. Psychotherapeutic Interventions

1. Behavioral modification

Behavioral modifications are designed to improve specific behaviors, social skills, and performance in specific settings. Behavioral approaches require detailed assessment of the child’s responses and the conditions that elicited them. Strategies are then developed to change the environment and the behaviors while maintaining and generalizing the behavioral changes. The most prudent approach to the treatment of ADHD is multimodal. The combination of psychosocial interventions and medications produces the best results.

2. Educational interventions

The education of children with ADHD is covered by three federal statutes: the Individuals with Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) of 1990. The diagnosis of ADHD alone does not suffice to qualify for special education services. The ADHD must impair the child’s ability to learn. A 1991 Department of Education Policy Clarification Memorandum specifies three categories by which ADHD children may be eligible for special education: (1) health impaired (other documented condition such as Tourette syndrome), (2) specific learning disability (could be ADHD alone if there is a significant discrepancy between a child’s cognitive ability or intelligence and his or her academic performance), and (3) seriously emotionally disturbed. It is therefore vital to document all comorbid conditions in these children.

3. Parent education and training

Parental understanding of ADHD is vital to successful treatment. Parents must know the difference between nonadherence and inability to perform. They need to understand that ADHD is not a choice but a result of nature. Many parents respond well to referral to local and national support groups such as Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) or the Attention Deficit Disorder Association (ADDA).

Parent training programs such as developed by Russell Barkley and others provide confused and overwhelmed parents with specific management strategies shown to be effective in reducing noncompliance. In these group training sessions, parents are taught skills in how to more effectively communicate with their children, learn how to consequate noncompliance, and enhance school performance.

Prognosis

Follow-up studies of children with ADHD show that adult outcomes vary greatly. There are three general outcome groups. The largest group is the 50–60% of affected children who continue to have concentration, impulsivity, and social problems in adulthood. About 30% of affected children function well in adulthood and have no more difficulty than controlled normal children. The final group represents about 10–15% who, in adulthood, have significant psychiatric or antisocial problems. Predictors for bad outcomes include comorbid CD, low IQ, and concurrent parental pathology.

General Considerations

The cause is generally related to social, parental, and child factors. A correlation exists between ODD and living in crowded conditions such as high-rise buildings with inadequate play space. There are strong correlations between the way parents act and oppositional behavior. Mothers, especially, demonstrate high levels of anxiety and depression. Family relationships, especially the marital relationship, tend to be strained. This sets up a vicious cycle as the child becomes increasingly insecure and more difficult to handle, conditions that prompt the parents to react with more rejection and anger.

Prevalence

The reported prevalence of ODD varies from 2% to 16% of children and adolescents. Studies show an increasing rate of diagnosis from late preschool or early school-aged children to grade school to middle school to high school and then a decrease in college-aged individuals. Unlike gender differences in CD and ADHD, they are minimal in ODD, and boys are only slightly more likely to receive a diagnosis of ODD than girls. Conclusive data on racial or cultural differences do not exist, but worldwide ODD and CD are more prevalent among families of low socioeconomic status who tend to live in close quarters.

Clinical Findings

Common manifestations of ODD include persistent stubbornness, résistance to directions, and unwillingness to negotiate and compromise with others. Defiant behaviors include persistent testing of limits, arguing, ignoring orders, and denying blame for most misdeeds. Hostility usually takes the form of verbal abuse and aggression. The most common setting is the home, and behavioral problems may not be evident to teachers or others in the community. Because the symptoms of the disorder are most likely to be manifested toward individuals that the patient knows well, they are rarely apparent during clinical examination. Children and adolescents with ODD do not see themselves as the problem but instead view their behavior as a reasonable response to unreasonable demands.

Differential Diagnosis

Diagnosis is made by parents, patient, or teacher history and direct observation.

Behavioral checklists are available that can identify the pattern of ODD. They include the Child Behavioral Checklist. It is rare that any medical testing or neuropsychiatric testing is necessary, unless comorbid states are present. The DSM-5 presents specific diagnostic criteria for ODD.

Complications

Oppositional defiant disorder is common among children and adolescents with ADHD. The combination of ADHD, ODD, family adversity, and low verbal IQ are predictors of progression to more serious CD and antisocial behaviors as adults. However, although ≤50% of ADHD children have ODD behaviors, only ~15% of those diagnosed with ODD have ADHD.

Approximately 15% of ODD children have anxiety disorders, and approximately 10% have depression of mood disorders. Addressing these problems can often help with the oppositional behaviors.

Treatment

A. Behavioral Therapy

The vast majority of these patients and their families can be managed with behavioral therapies, especially parental training and family therapy.

B. Medications for Oppositional Defiant Disorder

Medication for youth with ODD should not be the sole intervention and are primarily adjunctive, palliative, and noncurative. Medications may be beneficial in the context of other diagnoses and as such may be helpful adjuncts to a treatment package for symptomatic treatment and to treat comorbid conditions. For example, stimulants and atomoxetine may be useful in treating ODD in the context of another principal diagnosis such as ADHD. ODD behaviors in the context of an anxiety disorder or a depressive disorder may be successfully treated with a selective serotonin reuptake inhibitor (SSRI). Aggressive and oppositional behaviors complicate a wide range of other diagnoses in this age range. Therefore medications should target specific syndromes as much as possible.

C. Pharmacotherapy for Comorbid Conditions

There is no accepted pharmacologic treatment for oppositional behaviors, but comorbid conditions such as ADHD or depression must be properly addressed and appropriately treated. For children who do not respond to nonmedical interventions or are extremely impaired, it is best to consult a pediatric psychiatrist. Medications used for ODD, comorbid with other conditions, include clonidine, lithium, carbamazepine, valproic acid, and risperidone; all have significant risks, and their use should be monitored carefully.

Prognosis

The most serious consequence of ODD is the development of more dangerous conduct problems. Although the majority of children with ODD will not develop CD, in some cases ODD appears to represent a developmental precursors of CD. This seems to hold true for boys more than for girls. For children in whom such symptoms subsequently decrease with maturity, the prognosis is good. If oppositional behaviors progress and begin to involve the violation of others’ rights, then the child will probably progress to CD.

General Considerations

Conduct disorder also constitutes a public health concern by contributing to school and gang violence, weapon use, substance abuse, and high dropout rates. It is therefore important to identify these behaviors and intervene as early as possible.

The risk of CD is higher in children whose biological or adoptive parents have antisocial personality disorder, and siblings of children with CD have a higher risk for developing the condition as well. CD is also more common in children whose biological parents have ADHD, CD, alcohol dependence, mood disorders, and schizophrenia.

There is no doubt that the caregiver-child interaction contributes to disruptive behavior. Factors in these relationships include: (1) low levels of parental involvement in the child’s activities, (2) poor supervisions, and (3) harsh and inconsistent disciplinary practices. The child views behavioral problems as strategies to secure attention and becomes closer to the caregiver or parent. Neighborhood and peer factors also contribute to the incidence of CD. Poverty, living in crowded conditions in a high-crime neighborhood, and having a “deviant” peer group all increase the risk of CD.

Prevalence

The prevalence of CD varies from 1% to 10% overall, depending on the studied population, with ranges of 6–16% in boys and 2–9% in girls younger than 18 years. CD tends to increase from middle childhood to adolescence. Although certain behaviors (eg, physical fighting) decrease with age, the most serious aggressive behaviors (eg, robbery, rape, and murder) increase during adolescence. The differing incidence of CD in boys and girls does not occur until after age 6 years, and boys and girls with CD manifest differing behaviors. Boys exhibit more fighting, stealing, vandalism, and school discipline problems, whereas girls are more likely to lie, be truant, run away, and abuse substances.

Clinical Findings

There are four main groupings of behaviors in CD: (1) aggression toward people or animals, (2) destruction of property, (3) deceitfulness or theft, and (4) serious violation of rules. Behavioral disorders must be differentiated from normal reactions to abnormal circumstances. The DSM-5 states that the diagnosis of CD should not be made when behaviors are in response to the social context. Screening questions might include asking about troubles with police, involvement in physical fights, suspensions from school, running away from home, sexual activity, and the use of tobacco, alcohol, and drugs.

Differential Diagnosis

A clear majority (75%) of children with CD have at least one other psychiatric diagnosis. Of all children with CD, 30–50% also have ADHD. A significant proportion of children present with symptoms of both ADHD and CD, and both conditions should be diagnosed when this occurs. Comorbid ADHD and CD are consistently reported to be more disabling than either disorder alone. Finally, children with comorbid ADHD and CD appear to have a much worse long-term outcome than those with either disorder alone.

Other psychiatric diagnoses commonly seen in association with CD include anxiety disorders, mood disorders, substance abuse, schizophrenia, somatoform disorder, and obsessive-compulsive disorder. This is not surprising, considering that these diagnoses are more common in the parents of children with CD.

Intermittent explosive disorder features sudden aggressive outbursts that are usually unprovoked. These individuals do not intend to hurt anyone but say that they “snapped” and, without realizing it, attacked another person. Intermittent explosive disorder is distinguished from CD in that these episodes are the only signs of behavioral problems and these individuals do not engage in other rule violations. The treatise by Green (2010) is an excellent reference for diagnosis and treatment recommendations.

Treatment

A key element in the initial treatment of these children is to obtain parental involvement. Although many parents of children with CD have problems themselves, they do not want their children to follow their path. All parties need to be aware of the possibility of a poor prognosis without the interventions of the caregiver.

A. Behavioral Interventions

Behavioral interventions are similar to those for ODD. Collaborative resources such as school counselors, residential care, juvenile court designated workers, and the Department of Social Services can provide wraparound services for children and adolescents who are generally unmotivated and resistive to any type of intervention that may be necessary.

B. Psychopharmacology

Psychopharmacological interventions alone are insufficient to treat youth with CD. Medications are best seen as adjunctive treatments. Very often, youths with CD have other diagnoses. Because aggression, mood lability, and impulsivity may be seen in a wide range of comorbid diagnoses, these symptoms may be targets for pharmacological interventions. Antidepressants, anticonvulsants, lithium carbonate, α-agonists, and antipsychotics have been used clinically. The potential side effects of various classes of medications may potentially outweigh their benefits.

Prognosis

The social burden and public health concerns associated with CD make diagnosis and treatment of this condition very important. About 40% of children with early-onset CD are diagnosed in adulthood with antisocial personality disorder or psychopathology. Overall, approximately 30% of children with CD continue to demonstrate a repetitive display of illegal behaviors. Antisocial behavior rarely begins in adulthood, and the family cycle of such behaviors is difficult to break.