• Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. • Lamb, M. E. (Ed.). (2010). The role of the father in child development (5th ed). Hoboken, N.J.: Wiley. • Lovejoy, M. C., Weis, R., O'Hare, E., & Rubin, E. C. (1999). Development and initial validation of the Parent Behavior Inventory. Psychological Assessment. • Lundahl, B. W., Tollefson, D., Risser, H., & Lovejoy, M. C. (2007). A meta-analysis of father involvement in parent training. Research on Social Work Practice. • Macfadyen, A., Swallow, V., Santacroce, S., & Lambert, H. (2011). Involving fathers in research. Journal for Specialists in Pediatric Nursing. References: • Parent, J., McKee, L. G., & Forehand, R. (2016). Seesaw discipline: The interactive effect of harsh and lax discipline on youth psychological adjustment. Journal of Child and Family Studies • Paolacci, G., & Chandler, J. (2014). Inside the turk understanding mechanical turk as a participant pool. Current Directions in Psychological Science. • Paolacci, G., Chandler, J., & Ipeirotis, P. G. (2010). Running experiments on amazon mechanical turk. Judgment and Decision Making. • Patterson, G. R. (1982). Coercive family process (Vol. 3). Eugene, OR: Castalia Publishing Company. 101 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT –7 ATTENTION DEFICIT HYPER ACTIVITY DISORDERS- PART II Structure 7.0 LearningObjectives 7.1 Introduction 7.2 Warning Signs 7.3 Types of ADHD 7.4 Diagnosing ADHD 7.5 Biological Causes of ADHD 7.6 Treatment for ADHD 7.7 Summary 7.8 Keywords 7.9 Learning Activity 7.10 Unit End Questions 7.11 References 7.0 LEARNINGOBJECTIVES After, studying this unit, you will be able to • Describe the process of assessment for attention deficit and hyperactivity disorder. • Explain the psychological tests used by child psychologists • Describe the test used for attention deficit and hyperactivity disorder • Explain the concept of prognosis with respect to attention deficit and hyperactivity disorder • Explain the treatments available for attention deficit and hyperactivity disorder 102 CU IDOL SELF LEARNING MATERIAL (SLM)
7.1 INTRODUCTION The term hyperactive is familiar to most people, especially parents and teachers. The child who is constantly in motion—tapping fingers, jiggling legs, poking others for no apparent reason, talking out of turn, and fidgeting—is often called hyperactive. Often, these children also have difficulty concentrating on the task at hand for an appropriate period of time. When such problems are severe and persistent enough, these children may meet the criteria for diagnosis of attention-deficit/hyperactivity disorder (ADHD).The disruptive behavior disorders are abnormal behaviours that are expressed in many different forms. Such behaviours are usually portrayed as inappropriate among most individuals in a society. They are also called Behavioral Disorders. These behaviours also violate the social norms of others and especially towards their siblings. People “break the rules” a little all the time and children also, and especially the rules that they believe are not as important. Over time, children tend to mature and outgrow these disruptive behaviours. When they do not, psychological evaluation is usually advised as this behavior can lead to other more serious disorders (antisocial personality disorder, etc. All children and adolescents act out from time to time— having tantrums, testing boundaries, or questioning rules—especially if they’re overly distressed or tired. In fact, such behavior is an expected part of development in toddlers and young teens. But when behavioral problems disrupt a child’s family, school, and social life, it may indicate a more serious condition. Oppositional defiant disorder and conduct disorder are two types of behavioral disorders in children and teens. Other conditions may have similar symptoms or appear at the same time in a child with behavioral problems, including anxiety and other mood disorders, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and autism spectrum disorders. 7.2 WARNING SIGNS ADHD includes 3 behaviour symptoms: inattention, hyperactivity, and impulsivity. A child with inattention symptoms may have the following behaviours: • Has a hard time paying attention, daydreams 103 • Does not seem to listen • Is easily distracted from work or play • Does not seem to care about details, makes careless mistakes • Does not follow through on instructions or finish tasks • Is disorganized • Loses a lot of important things • Forgets things • Does not want to do things that require ongoing mental effort CU IDOL SELF LEARNING MATERIAL (SLM)
A child with hyperactivity symptoms may have the following behaviours: • Is in constant motion, as if “driven by a motor” • Cannot stay seated • Squirms and fidgets • Talks too much • Runs, jumps, and climbs when this is not permitted • Cannot play quietly (video games do not count) A child with impulsivity symptoms may have the following behaviours: • Acts and speaks without thinking • May run into the street without looking for traffic first • Has trouble taking turns • Cannot wait for things • Calls out answers before the question is complete • Interrupts others ADD stands for Attention Deficit Disorder. This is an old term that is now officially called Attention Deficit Hyperactivity Disorder, Inattentive Type. More on this will discussed below. 7.3 TYPES OF ADHD Children with ADHD may have one or more of the 3 main symptoms categories listed above. The symptoms usually are classified as the following types of ADHD: 1. Inattentive type (formerly known as attention-deficit disorder [ADD])—Children with this form of ADHD are not overly active. Because they do not disrupt the classroom or other activities, their symptoms may not be noticed. Among girls with ADHD, this form is most common. Inattentive type – six (or five for people over 17 years) of the following symptoms occur frequently: • Doesn’t pay close attention to details or makes careless mistakes in school or job tasks. • Has problems staying focused on tasks or activities, such as during lectures, conversations, or long reading. • Does not seem to listen when spoken to (i.e., seems to be elsewhere). • Does not follow through on instructions and doesn’t complete schoolwork, chores, or job duties (may start tasks but quickly loses focus). 104 CU IDOL SELF LEARNING MATERIAL (SLM)
• Has problems organizing tasks and work (for instance, does not manage time well; has messy, disorganized work; misses deadlines). • Avoids or dislikes tasks that require sustained mental effort, such as preparing reports and completing forms. • Often loses things needed for tasks or daily life, such as school papers, books, keys, wallet, cell phone and eyeglasses. • Is easily distracted. • Forgets daily tasks, such as doing chores and running errands. Older teens and adults may forget to return phone calls, pay bills, and keep appointments. 2. Hyperactive/Impulsive type—Children with this type of ADHD show both hyperactive and impulsive behaviour, but can pay attention. Hyperactive/impulsive type – six (or five for people over 17 years) of the following symptoms occur frequently: • Fidgets with or taps hands or feet, or squirms in seat. • Not able to stay seated (in classroom, workplace). • Runs about or climbs where it is inappropriate. • Unable to play or do leisure activities quietly. • Always “on the go,” as if driven by a motor. • Talks too much. • Blurts out an answer before a question has been finished (for instance may finish people’s sentences, can’t wait to speak in conversations). • Has difficulty waiting his or her turn, such as while waiting in line. • Interrupts or intrudes on others (for instance, cuts into conversations, games, or activities, or starts using other people’s things without permission). Older teens and adults may take over what others are doing. 3. Combined Inattentive/Hyperactive/Impulsive type—Children with this type of ADHD show all 3 symptoms. This is the most common type of ADHD. There is no lab test to diagnose ADHD. Diagnosis involves gathering information from parents, teachers, and others, filling out checklists and having a medical evaluation (including vision and hearing screening) to rule out other medical problems. The symptoms are not the result of person being defiant or hostile or unable to understand a task or instructions. 7.4 DIAGNOSING ADHD There isn’t a simple test that can diagnose ADHD. Children usually display symptoms before the age of 7. But ADHD shares symptoms with other disorders. Your doctor may first try to rule out conditions like depression, anxiety, and certain sleep issues before making a 105 CU IDOL SELF LEARNING MATERIAL (SLM)
diagnosis. The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM- 5) is used across the United States to diagnose children and adults with ADHD. It includes a detailed diagnostic evaluation of behaviour. A person must show at least six of the nine major symptoms for a specific type of ADHD. To be diagnosed with combination ADHD, you must show at least six symptoms of inattention and hyperactive-impulsive behaviour. The behaviours must be present and disruptive to everyday life for at least six months. Besides showing the pattern of inattention, hyperactivity-impulsivity, or both, the DSM-5 states that to be diagnosed, a person’s symptoms must be displayed before 12 years of age. And they must be present in more than just one setting, like at both school and home. Symptoms must also interfere with everyday life. And these symptoms can’t be explained by another mental disorder. An initial diagnosis may reveal one type of ADHD. But symptoms can change over time. This is important information for adults, who may need to be revaluated. 7.5 BIOLOGICAL CAUSES OF ADHD ADHD is one of the most studied conditions of childhood but the cause of ADHD is still not clear at this time. The most popular current theory of ADHD is that ADHD represents a disorder of “executive function.” This implies dysfunction in the prefrontal lobes so that the child lacks the ability for behavioural inhibition or self-regulation of such executive functions as nonverbal working memory, speech internalization, affect, emotion, motivation, and arousal. It is believed that children with ADHD lack the right balance of neurotransmitters, which are specific chemicals in their brains that help them to focus and inhibit impulses. Because of this relative inability to inhibit, the child lives pretty much only in the “now” and lacks the ability to modify or delay behaviour in view of future consequences. Since children with ADHD are often unaware of their behaviour, they may become defiant and may even lie and claim, “I didn’t do it!” The cause(s) and risk factors for ADHD are unknown, but current research shows that genetics plays an important role. Recent studies of twins link genes with ADHD.1 In addition to genetics, scientists are studying other possible causes and risk factors including: • Brain injury • Exposure to environmental (e.g., lead) during pregnancy or at a young age • Alcohol and tobacco use during pregnancy • Premature delivery • Low birth weight 106 CU IDOL SELF LEARNING MATERIAL (SLM)
Research does not support the popularly held views that ADHD is caused by eating too much sugar, watching too much television, parenting, or social and environmental factors such as poverty or family chaos. Of course, many things, including these, might make symptoms worse, especially in certain people. But the evidence is not strong enough to conclude that they are the main causes of ADHD. Genetics ADHD runs in families. Anywhere from one-third to one-half of parents with ADHD will have a child with the disorder. There are genetic characteristics that seem to be passed down. If a parent has ADHD, a child has more than a 50% chance of having it. If an older sibling has it, a child has more than a 30% chance. Pregnancy Problems Children born with a low birth weight, born premature, or whose mothers had difficult pregnancies have a higher risk of having ADHD. The same is true for children with head injuries to the frontal lobe of the brain, the area that controls impulses and emotions. Studies show that pregnant women who smoke or drink alcohol may have a higher risk of having a child with ADHD. Exposure to lead, PCBs, or pesticides may also have a role. Brain Circuits Studies show that brain chemicals, called neurotransmitters, don’t work the same in children and adults with ADHD. There also tend to be differences in the way nerve pathways work. Certain parts of the brain may be less active or smaller in children with ADHD than those without the disorder. The brain chemical dopamine may also play a role. It carries signals between nerves in the brain and is linked to movement, sleep, mood, attention, and learning. 7.6 TREATMENT FOR ADHD 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 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. 107 CU IDOL SELF LEARNING MATERIAL (SLM)
Treatment for attention deficit hyperactivity disorder (ADHD or ADD) isn’t just about taking medication. There are many other effective treatments that can help kids with ADHD improve their ability to pay attention, control impulsive behaviour, and curb hyperactivity. Nutritious meals, play and exercise, learning new coping skills, and improving social skills are all part of a balanced treatment plan that can improve your child’s performance at school, bolster their relationships with others, and decrease stress and frustration—for them and for your whole family. Ritalin has been shown to be effective in the short-term treatment of ADHD. 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. Three other medications for treating ADHD have received attention in recent years. Pemoline is chemically very different from Ritalin it exerts beneficial effects on classroom behavior by enhancing cognitive processing but has less adverse side effects. Strattera (atomoxetine), a non-controlled treatment option that can be obtained readily, is an FDA-approved non- stimulant medication. 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 dextroamphetamine; however, research has suggested that Adderall has no advantage or improvement in results over Ritalin or Strattera. 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 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. Ritalin has been shown to be effective in the short-term treatment of ADHD. 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. Three other medications for treating ADHD have received attention in recent years. Pemoline is chemically very different from Ritalin it exerts beneficial effects on classroom behavior by enhancing cognitive processing but has less adverse side effects. Strattera (atomoxetine), a non-controlled treatment option that can be obtained readily, is an FDA-approved non- stimulant medication. Another drug that reduces symptoms of impulsivity and hyperactivity 108 CU IDOL SELF LEARNING MATERIAL (SLM)
in children with attention deficit/hyperactivity disorder is Adderall. This medication is a combination of amphetamine and dextroamphetamine; however, research has suggested that Adderall has no advantage or improvement in results over Ritalin or Strattera. ADHD medication Stimulants such as Ritalin and Adderall are often prescribed for ADHD, but they might not be the best option for your child—and they’re certainly not the only treatment. Medications for ADHD may help your child concentrate better or sit still, at least in the short term. But to date, there is little evidence that they improve school achievement, relationships, or behavioural issues over the long term. And even in the short term, medication won’t solve all problems or completely eliminate the symptoms of ADHD. Furthermore, there are concerns about the effects these powerful drugs may have on a child’s developing brain. And the side effects—such as irritability, loss of appetite, and insomnia— can also be problematic. The bottom line: medication is a tool, not a cure. Everyone responds differently to ADHD medication. Some children experience dramatic improvement while others experience little to no relief. The side effects also differ from child to child and, for some, they far outweigh the benefits. Because everyone responds differently, finding the right medication and dose takes time. Medication for ADHD is more effective when combined with other treatments. Your child will get much more out of your medication if they are also taking advantage of other treatments that teach new coping skills. ADHD medication should always be closely monitored. Medication treatment for ADHD involves more than just taking a pill and forgetting about it. Your child’s doctor will need to monitor side effects, keep tabs on how your child is feeling, and adjust the dosage accordingly. When medication for ADHD is not carefully monitored, it is less effective and riskier. If you choose to put your child on medication, that doesn’t mean they have to stay on it forever. Although it isn’t safe to bounce off and on any drug repeatedly, you can safely decide to stop treating your child’s ADHD with medication if things aren’t going well. If you want your child to stop taking medication, be sure to let your doctor know your plans and work with them to taper off the drugs slowly. 109 CU IDOL SELF LEARNING MATERIAL (SLM)
ADHD treatment starts at home As a parent, you have a huge influence over your child’s treatment. Evidence shows that eating a healthy diet, getting plenty of exercise, and making other smart daily choices can help your child manage the symptoms of ADHD. That means your child can begin treatment for ADHD today—at home. The power of exercise in the treatment of ADHD Exercising is one of the easiest and most effective ways to reduce the symptoms of ADHD. Physical activity immediately boosts the brain’s dopamine, norepinephrine, and serotonin levels—all of which affect focus and attention. In this way, exercise, and medications for ADHD such as Ritalin and Adderall work similarly. But unlike ADHD medication, exercise doesn’t require a prescription and it’s free of side effects. Activities that require close attention to body movements, such as dance, gymnastics, martial arts, and skateboarding, are particularly good for kids with ADHD. Team sports are also a good choice. The social element keeps them interesting. The benefits of “green time” Studies show that spending time in nature can reduce the symptoms of ADHD in children. Encourage your child to play outside for at least 30 minutes each day, if possible. The importance of sleep in ADHD treatment Regular quality sleep can lead to vast improvement in the symptoms of ADHD. However, many kids with ADHD have problems getting to sleep at night. Sometimes, these sleep difficulties are due to stimulant medications, and decreasing the dose or stopping the medication entirely will solve the problem. However, a large percentage of children with ADHD who are not taking stimulants also have sleep difficulties. If your child is one of them, the following tips can help. • Set a regular bedtime (and enforce it). • If background noise keeps your child up, try a sound machine or a fan. • Turn off all electronics (TV, computer, video games, iPhone) at least an hour before bed. • Limit physical activity in the evening. Good nutrition help reduce ADHD symptoms 110 CU IDOL SELF LEARNING MATERIAL (SLM)
Studies show that what, and when, you eat makes a difference when it comes to managing ADHD. Schedule regular meals or snacks no more than three hours apart. This will help keep your child’s blood sugar steady, minimizing irritability and supporting concentration and focus. Try to include a little protein and complex carbohydrates at each meal or snack. These foods will help your child feel more alert while decreasing hyperactivity. Check your child’s zinc, iron, and magnesium levels. Many children with ADHD are low in these important minerals. Boosting their levels may help control ADHD symptoms. Increasing iron may be particularly helpful. One study found that an iron supplement improved symptom almost as much as taking stimulant medication. Add more omega-3 fatty acids to your child’s diet. Studies show that omega-3s reduce hyperactivity and impulsivity and enhance concentration in kids (and adults) with ADHD. Omega-3s are found in salmon, tuna, sardines, and some fortified eggs and milk products. However, the easiest way to boost your child’s intake is through fish oil supplements. Professional treatment for ADHD Although there are many ways you can help a child with ADHD at home, you may want to seek professional help along the way. ADHD specialists can help you develop an effective treatment plan for your child. Since ADHD responds best to a combination of treatments and strategies, consulting several specialists is advisable. To find ADHD treatment providers, you may want to contact your primary care physician, your child’s paediatrician, local hospitals, or clinics. Other sources for provider references include your insurance company, officials at your child’s school, or a local parent support group. Child and adolescent psychiatrists: • Diagnose ADHD and prescribe medications • Psychologists: • Diagnose ADHD and provide talk therapy • Help people with ADHD explore their feelings Cognitive-behavioural therapists: • Set up behavioural modification programs at school, work, and home 111 • Establish concrete goals for behaviour and achievement CU IDOL SELF LEARNING MATERIAL (SLM)
• Help families and teachers maintain rewards and consequences Educational specialists: • Teach techniques for succeeding in school • Help children obtain accommodations from school • Advise families about assistive technology Behavioural therapy for ADHD Behavioural therapy, also known as behaviour modification, has been shown to be a very successful treatment for children with ADHD. It is especially beneficial as a co-treatment for children who take stimulant medications and may even allow you to reduce the dosage of the medication. Behaviour therapy involves reinforcing desired behaviours through rewards and praise and decreasing problem behaviours by setting limits and consequences. For example, one intervention might be that a teacher rewards a child who has ADHD for taking small steps toward raising a hand before talking in class, even if the child still blurts out a comment. The theory is that rewarding the struggle toward change encourages the full new behaviour. Therapy Behavioural therapy may help individuals with attention deficit hyperactivity disorder (ADHD) manage and change the behaviours that are causing them difficulties and stress. ADHD symptoms can lead to a variety of behaviours that may make everyday tasks feel challenging or even impossible. Behavioural therapy symptoms more effectively. Behavioural therapy may work alongside medication and is often a part of an ADHD treatment plan. What is behavioural therapy for ADHD? People with ADHD have symptoms that can make it difficult for them to succeed at school, work, or everyday tasks. Behavioural therapy can help people with ADHD learn skills that control their symptoms and help them manage tasks. The goal of behavioural therapy is to replace negative behaviours with positive ones. Behavioural therapy does this by teaching strategies to improve problem areas like organization, focus, and impulse control. 112 CU IDOL SELF LEARNING MATERIAL (SLM)
Some people find that behavioural therapy helps them effectively manage their ADHD symptoms without medication. Other people use behavioural therapy alongside medication. Behavioural therapy doesn’t affect the actual symptoms of ADHD. It won’t change how a child or adult with ADHD’s brain works. However, it can teach people with ADHD skills that make it much easier to succeed at school, work, home, and in relationships. When children have behavioural therapy for ADHD, their parents or guardians are involved in the process. Families will work with a therapist to set goals, and therapists will help families use behavioural therapy techniques at home and at school. According to the Centres for Disease Control and Prevention (CDC) Trusted Source, behavioural therapy and cognitive behavioural therapy are helpful in reducing symptoms in children with ADHD. When adults have behavioural therapy for ADHD, they normally have a type of therapy called cognitive behavioural therapy (CBT). CBT may help adults with ADHD recognize how their own thoughts affect their behaviours. It works to help adults with ADHD reframe their thoughts so they have more positive behaviours and more control over their ADHD symptoms. How does behavioural therapy for ADHD work for children? Behavioural therapy for children with ADHD takes a whole family approach to change behaviours. All behavioural therapy focuses on changing a person’s actions. Behavioural therapy for children with ADHD also looks at how negative actions are responded to in a child’s home. In many cases, parents of children with ADHD are unintentionally reinforcing negative behaviours. That’s why a therapist will sit down with a family to help create a plan. The plan will help the entire family set goals and work on changing behaviours. Therapy sessions will give children and their parents the tools they need to successfully make changes. Children will learn new skills and new ways to manage tasks that might be challenging for them, such as: • completing homework • paying attention in class • keeping their rooms clean • completing any daily chores 113 CU IDOL SELF LEARNING MATERIAL (SLM)
Parents will learn new methods of helping their child with ADHD succeed, and they’ll learn about why certain strategies aren’t effective. The therapist will introduce new strategies for rewarding positive behaviours and managing negative ones. What to expect during behavioural therapy for ADHD in children? At your child’s first appointment, you’ll sit down with the therapist to discuss goals. You’ll talk about which behaviours are the most are challenging. The therapist will help you come up with a plan to work on those behaviours. The plan will involve setting up a system of rewards and consequences in your home. You’ll create a chart listing the actions your child needs to take to meet goals and earn rewards. The therapist will help your child select rewards that will motivate them. This chart will help your child see exactly what they need to do to meet expectations every day. For example, if your child has trouble staying with their class and not running down the school hall to the gym or cafeteria, you could make walking safely with the rest of the class a goal. The chart would be set up so that every day your child walked safely with the class; they’d earn a point. You could then establish that five points would earn them extra time doing a favourite activity. Children should be praised and encouraged when they complete tasks and earn rewards. When tasks aren’t completed, they won’t earn those points. It’s important that they’re not punished or shamed for not completing tasks. Not earning a point is the consequence. The goal is to encourage positive behaviours. You’ll meet with the therapist on a weekly basis to discuss how the chart is going and work out any issues you’ve encountered. Your child will also have sessions with the therapist, typically once a month. They’ll learn skills that can help them complete the tasks on the chart. They’ll learn strategies that will make it easier for them to reach their goals at home and at school. They’ll also learn ways to manage their anger and improve their self-control. It’s important to involve your child’s teacher in their therapy and plan, especially if they have school-related goals. That way teachers can see that tasks are being completed and report back to parents. This can give children feedback every day on their school performance and help them improve. Some children benefit from a specific at-school chart system. Your child’s teacher can work with you to set this up. Generally, teachers will fill out a daily report. The report will have a list of in-school tasks or positive behaviours your child needs to accomplish. Every day, their 114 CU IDOL SELF LEARNING MATERIAL (SLM)
teacher will mark whether each task or behaviour was accomplished. Your child can then earn a small reward if they come home with enough marks on their daily report. Behavioural therapy for adults looks a little different. Adults with ADHD have different challenges and need different strategies. Many adults with ADHD struggle with time management, disorganization, lack of motivation, and difficulties regulating their emotions. This often causes low self-esteem, high stress, constant feelings of defeat, and other negative thought processes. Adults with ADHD might think their struggles are their fault and might have trouble believing that things will ever go well or that they will ever succeed. If you’re an adult with ADHD, CBT can help you overcome these negative thought processes. Rather than teaching new strategies for organization or task completion, CBT can help you reframe your thoughts. The goal is to change negative behaviours by changing the thought process that can fuel them. CBT will help you look at past struggles and difficulties. During sessions, you can examine what role your ADHD symptoms had in those situations. You’ll work with the therapist to break down the situation. You’ll look at the thoughts, emotions, and behaviours you had during the situation. You’ll then start to look at other ways the situation could have been managed, and build coping techniques to avoid the situation of the future. Other ways CBT can help adults with ADHD include help with: • managing negative emotions • resetting negative expectations • figuring out any behavioural patterns • coping with stress • navigation transitions throughout the day • dealing with stressful obligations • making time for self-care and self-fulfilment • changing self-defeating behaviours CBT can teach you new ways to manage your everyday life. You’ll focus on things that will work for you and the specific ways your ADHD affects your life. The strategies will be designed for you and for your struggles. 115 CU IDOL SELF LEARNING MATERIAL (SLM)
CBT can also help you manage other conditions or issues you might have along with ADHD. For example, it’s not uncommon for people with ADHD to have mood disorders like anxiety or depression, to struggle with addiction, or to have difficulty maintaining a healthy lifestyle. During CBT sessions, your therapist can work with you on those issues too. You’ll learn how other conditions can interact with your ADHD and discuss ways to better manage and cope with your symptoms. Cognitive Behavioural Therapy After a lifetime of mistakes, mishaps, and missed deadlines, is it any wonder that adults with attention deficit hyperactivity disorder (ADHD or ADD) suffer dangerously low self-esteem and perpetually negative thoughts? Cognitive behavioural therapy (CBT) is a short-term, goal-oriented form of psychotherapy that aims to change these negative patterns of thinking and change the way a patient feels about herself, her abilities, and her future. Consider it brain training for ADHD. Originally a treatment for mood disorders, CBT is based on the recognition that cognitions, or automatic thoughts, lead to emotional difficulties. Automatic thoughts are spontaneous interpretations of events. These impressions are susceptible to distortion, such as unfounded assumptions about yourself (or others), a situation, or the future. Such unhealthy internal dialogs hinder an individual from working toward an intended goal, working to develop productive new habits, or generally take calculated risks. CBT aims to change irrational thought patterns that prevent individuals from staying on task or getting things done. For an individual with ADHD who thinks, “This has to be perfect or it’s no good,” or “I never do anything right,” CBT challenges the truth of those cognitions. Changing distorted thoughts, and the resulting change in behaviour patterns, is effective in treating anxiety, and other emotional problems. ADHD is a chronic, persistent delay of self-regulation skills, including executive functioning skills. Delays in EFs create procrastination, disorganization, poor time management, emotional dysregulation, impulsivity, and inconsistent motivation. Although these problems are not included in the official diagnostic criteria for ADhD, they are common in adults with the condition, making it hard for them to regulate their emotions and behaviours. Individuals who grow up with ADHD (particularly if it has gone undiagnosed) encounter more frequent and frustrating setbacks in life situations — on the job, in social interactions, and everyday organization. Because of these many setbacks, adults with ADHD become self- critical and pessimistic. This, in turn, sometimes causes them to experience negative emotions, cognitive distortions, and unhealthy self-beliefs. It is common for individuals 116 CU IDOL SELF LEARNING MATERIAL (SLM)
living with ADHD to think they are at fault when situations don’t turn out well, when, in many cases, they aren’t. They may bring the same pessimism to the future, imagining that tomorrow will go as badly as today. Demoralizing thoughts and beliefs that keep individuals from doing what they want to do actually can’t stand up to the light of logic. As CBT reveals, these thought processes are distorted in certain characteristic ways: • All-or-nothing thinking. You view everything as entirely good or entirely bad: If you don’t do something perfectly, you’ve failed. • Overgeneralization. You see a single negative event as part of a pattern: For example, you always forget to pay your bills. • Mind reading. You think you know what people think about you or something you’ve done — and it’s bad. • Fortune telling. You predict that things will turn out badly. • Magnification and minimization. You exaggerate the significance of minor problems while trivializing your accomplishments. • “Should” statements. You focus on how things should be, leading to severe self- criticism as well as feelings of resentment toward others. • Personalization. You blame yourself for negative events and downplay the responsibility of others. • Mental filtering. You see only the negative aspects of any experience. • Emotional reasoning. You assume that your negative feelings reflect reality: Feeling bad about your job means “I’m doing badly and will probably get fired.” • Comparative thinking. You measure yourself against others and feel inferior, even though the comparison may be unrealistic. Learning to recognize these distorted thoughts helps you to replace them with realistic thinking. Since 1999, various research initiatives have studied the impact of CBT on the symptoms of ADHD in adults, in both individual and group formats, with a majority of the studies being published in the past 5-10 years. By and large, this research supports the assertion that CBT can help adults better address their ADHD-related challenges. For example, a 2016 neuroimaging study of adults with ADHD who completed a 12-session course of CBT showed improvements in ADHD symptom ratings and beneficial changes in the same brain regions that are typically monitored in studies of medication treatment. Still, some in the scientific community would like to see more rigorous research conducted with carefully constructed controls. In its 2011 report titled, “Current Status of Cognitive 117 CU IDOL SELF LEARNING MATERIAL (SLM)
Behavioural Therapy for Adults Attention-Deficit Hyperactivity Disorder,” researchers from Massachusetts General Hospital and Harvard Medical School wrote: “The conceptual and empirical basis for CBT approaches in adult ADHD is growing and suggests that targeted, skills-based interventions have a role in effectively treating this disorder. At this stage of development, however, subsequent studies must progress in terms of methodological rigor. Additional randomized controlled trials with active control groups are needed and intervention packages must be tested across multiple trials by more than one research group.” While it is fascinating to learn how CBT may change the brain, most patients with ADHD just want to get out the door without wasting 20 minutes looking for their keys. CBT helps patients manage such everyday challenges. CBT intervenes to improve daily life struggles — procrastination, time management, and other common difficulties — not to treat the core symptoms of inattention, hyperactivity, and impulsivity. CBT sessions focus on identifying the situations in which poor planning, disorganization, and poor time and task management create challenges in a patient’s day-to-day life. Sessions may help an individual deal with obligations such as paying bills or completing work on time, and encourage endeavours that provide personal fulfilment and well-being, such as sleep, exercise, or hobbies. Learning about ADHD is always a good starting point, as it reinforces the message that ADHD is not a character flaw and demonstrates the neurological underpinnings of daily challenges. Most adults with ADHD say, “I know what I need to do, I just don’t do it.” Despite having plans for what they want or need to do, they do not carry them out. CBT focuses on adopting coping strategies, managing negative expectations and emotions, and unwinding behavioural patterns that interfere with the strategies. The goals and session agendas of CBT centre on scenarios and challenges that the patient has encountered and, more important, expects to encounter, particularly between sessions. The therapist uses take-away reminders, follow-up check-ins, and other ways of applying new coping skills so they are used outside of the consulting room. Ultimately, the way that a patient with ADHD functions in everyday life is the best measure of whether the therapy is helping. Results come quickly. CBT typically yields benefits after only 12 to 15 one-hour sessions. However, most patients continue with CBT much longer, as it emphasizes long-term maintenance of coping skills and improvements. In fact, the length of time spent in treatment — over many months, say — is as important as the number of sessions a person undergoes. 118 CU IDOL SELF LEARNING MATERIAL (SLM)
Some people ask whether they should take a month off from work or school and do a CBT “boot camp” for four or five weeks. This is generally not recommended. CBT aims to help individuals make sustained changes in their daily lives. Instead of attending 20 daily sessions of CBT in a month, a patient should stretch out those sessions over six months to turn his new skills into habits and to weave them into his lifestyle. This allows time and practice for mastering coping strategies for paying monthly bills, organizing work or school issues, and pursuing other tasks and endeavours in real time. Some individuals return to CBT for “booster sessions” to address a challenge if they’ve fallen into old habits. Some resume CBT to adapt their coping skills to a major life change, such as having a child or losing a job. Medication Therapy ADHD includes a multifaceted treatment and the focus is on reducing ADHD symptoms and improving functioning. Effective treatment examples include long-term medication therapy, academic intervention, and cognitive behavioural therapy. Medication (stimulant and non- stimulant) often provides the first line of treatment for many individuals with ADHD, but not all. The 2017 Merit-based Incentive Payment System (MIPS) includes an important physician ADHD medication quality measure on the percentage of children from six to 12 years of age that were newly dispensed a medication for ADHD who had appropriate follow-up care. The MIPS quality measure details can be viewed online at https://qpp.cms.gov/mips/quality- measures. ICD-10-CM code Z79.899, Other long term (current) drug therapy, should be assigned for ADHD individuals who are treated with long-term medication therapy. This status code assignment will assist in differentiating between ADHD individuals who are treated long- term with medication therapy versus ADHD individuals who do not receive long-term medication therapy. 7.7 SUMMARY • When a child is diagnosed with attention-deficit/hyperactivity disorder (ADHD), parents often have concerns about which treatment is right for their child. ADHD can be managed with the right treatment. There are many treatment options, and what works best can depend on the individual child and family. 119 CU IDOL SELF LEARNING MATERIAL (SLM)
• Treatments range from behavioral intervention to prescription medication. In many cases, medication alone is an effective treatment for ADHD. • Central nervous system (CNS) stimulants are the most commonly prescribed class of ADHD drugs. These drugs work by increasing the amounts of the brain chemicals called dopamine and norepinephrine. The effect improves your child’s concentration and helps them focus better. • Certain nonstimulant medications work by increasing levels of norepinephrine in your child’s brain. Norepinephrine is thought to help with attention and memory. • Psychotherapy can be useful in getting your child to open up about their feelings of coping with ADHD. ADHD can cause your child to have problems with peers and authority figures. Psychotherapy can help children better handle these relationships. • The goal of behaviour therapy is to teach a child how to monitor their behaviors and then change those behaviors appropriately • Social skills training can sometimes be useful if a child shows serious issues dealing with social environments. As with behaviour therapy, the goal of social skills training is to teach the child new and more appropriate behaviors. 7.8 KEYWORDS • Neurotransmitters: Neurotransmitters are chemical messengers that transmit a signal from a neuron across the synapse to a target cell, which can be a different neuron, muscle cell, or gland cell. Neurotransmitters are chemical substances made by the neuron specifically to transmit a message. • Hyperactivity: Hyperactivity is a state of being unusually or abnormally active. It's often difficult to manage for people around the person who's hyperactive, such as teachers, employers, and parents. If you have hyperactivity, you may become anxious or depressed because of your condition and how people respond to it • Impulsivity: Impulsivity is the tendency to act without thinking, for example if you blurt something out, buy something you had not planned to, or run across the street without looking. To a degree, this kind of behaviour is common, especially in children or teenagers, and isn't necessarily a sign of trouble. • Cognitive testing: Cognitive testing, also called neurocognitive testing or psychometric testing, assesses your ability to think clearly and to determine if any mental conditions exist. • Psychological assessment: Psychological assessment is a series of tests conducted by a psychologist, to gather information about how people think, feel, behave and react. • Cognitive test: Cognitive test measures a person’s cognitive abilities— problem solving, reasoning, vocabulary, comprehension, and memory. 120 CU IDOL SELF LEARNING MATERIAL (SLM)
• Educational testing: Educational testing is conducted to test how much an individual has progressed in learning a specific subject—like mathematics, reading comprehension—to identify any difficulties they may have had in it. • Neuropsychological tests: Neuropsychological tests analyse how an individual’s brain works, in order to identify any problems in its functioning. 7.9 LEARNING ACTIVITY 1. What are the precautions parents must take so that children with ADHD do not harm themselves accidently? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. How can schools and teachers help a child with ADHD to focus in the classroom? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 7.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What are causes of ADHD (Attention Deficit Hyperactivity Disorder)? 2. What are the symptoms of ADHD? 3. What is the difference between ADD (Attention Deficit Disorder) vs. ADHD? 4. Diagnosing ADHD 5. What are ADHD treatment options? Long Questions 1. How is behaviour therapy done in schools? 2. How does behaviour therapy for ADHD work for adults? 3. What Is CBT (Cognitive Behavioural Therapy)? 4. How Does CBT Help People with ADHD? 5. What is Disruptive Mood Dysregulation Disorder B. Multiple Choice Questions 121 CU IDOL SELF LEARNING MATERIAL (SLM)
1. Behavioral disorders may involve: a. Inattention b. Hyperactivity c. Criminal Activity d. All of these 2. Children with this form of ADHD are not overly active. a. Combined Inattentive b. Hyperactivity c. Inattentive d. Impulsivity 3. Also known as behavior modification. Involves reinforcing desired behaviors through rewards and praise and decreasing problem behavior by setting limits and consequences. a. Behavioral therapy b. Cognitive Behavioral therapy c. Cognitive Therapy d. Medication Therapy 4. Is a new DSM-5 addition that is characterized by severe and recurrent temper outburst that are grossly out of proportion in intensity or duration to the situation. a. Disruptive Disorder b. Disruptive Mood Dysregulation Disorder c. Social Communication Disorder d. Child Mental Disorder 5. This refers to a diagnosed mental health person that substantially disrupts a child’s ability to function socially, academically, and emotionally. a. Caseness b. Diagnostic system c. Serious emotional disturbance d. Mental Disorder Answers 1-(d), 2-(c), 3-(a), 4-(b), 5-(c) 7.11 REFERENCES Textbook 122 CU IDOL SELF LEARNING MATERIAL (SLM)
• Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. • American PsychiatricAssociation (2000).Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC:American Psychiatric Publishing, Inc.. • Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. • Armstrong TD, Costello EJ (2002), Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. J Consult Clin Psychol. · • Banaschewski T, Brandeis D, Heinrich H, Albrecht B, Brunner E, Rothenberger A (2003), Association of ADHD and conduct disorder - brain electrical evidence for the existence of a distinct subtype. J Child Psychol Psychiatr • .Bannerje T (1997), Psychiatric morbidity among rural primary school children in West Bengal Indian J Psychiat • Barkley RA(1987). Defiant children: a clinician’s manual for parent training. NewYork: Guilford. References: • Campbell SB (2002), Behavior Problems in Preschool Children: Clinical and Developmental Issues. New York: Guilford. • Campbell SB, Shaw DS, Gilliom M (2000), Early externalizing behavior problems: toddlers and preschoolers at risk for later maladjustment. Dev Psychopathol. • Cantwell DP, Swanson J, Connor DF (1997), Case study: adverse response to clonidine. J Am Acad Child Adolesc Psychiatry • Carey G, DiLalla D (1994), Personality and psychopathology: genetic perspectives. J Abnormal Psychol. 123 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT –8 CASE STUDIES Structure 8.0 LearningObjectives 8.1 Introduction 8.2 Case of Alice 8.3 Case of James 8.4 Case of Eric 8.5 Case of Gina 8.6 Case of Danny 8.7 Case of Tom 8.8 Case of Timmy 8.9 Summary 8.10 Keywords 8.11 Learning Activity 8.12 Unit End Questions 8.13 References 8.0 LEARNINGOBJECTIVES After studying this unit, you will be able to: • Explain the prevalence for learning disorder through different case studies • Explain the symptoms for learning disorder through different case studies • Explain the treatment for learning disorder through different case studies 124 CU IDOL SELF LEARNING MATERIAL (SLM)
• Explain the prevalence for attention deficit and hyperactivity disorder through different case studies • Explain the symptoms for attention deficit and hyperactivity disorder through different case studies • Explain the treatment for attention deficit and hyperactivity disorder through different case studies 8.1 INTRODUCTION 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. In this unit, we will look into case studies specific to mental retardation, learning disability and ADHD. It important to understand the way in which a child will present the symptoms when he comes to you for assessment. It is imperative that we see the behaviour and expression of the child in its context and not look out for syptoms. This gives us a wholistic understandong of the case. It also helps us in making an accurate dianosis and a better intervention plan. In this unit, we will see six different case of learning disorder and ADHD. 8.2 CASE OF ALICE Alice, a 20-year-old college student, sought help because of her difficulty in several of her classes. She reported that she had enjoyed school and had been a good student until about the sixth grade, when her grades suffered signifi cantly. Her teacher informed her parents that she wasn’t working up to her potential and she needed to be better motivated. Alice had always worked hard in school but promised to try harder. However, with each report card her mediocre grades made her feel worse about herself. She managed to graduate from high school, but by that time she felt she was not as bright as her friends. Alice enrolled in the local community college and again found herself struggling with the work. Over the years, she had learned several tricks that seemed to help her study and at least get passing grades. She read the material in her textbooks aloud to herself; she had earlier 125 CU IDOL SELF LEARNING MATERIAL (SLM)
discovered that she could recall the material much better this way than if she just read silently to herself. In fact, reading silently, she could barely remember any of the details just minutes later. After her sophomore year, Alice transferred to the university, which she found even more demanding and where she failed most of her classes. After our fi rst meeting, I suggested that she be formally assessed to identify the source of her diffi culty. As suspected, Alice had a learning disability. Scores from an IQ test placed her slightly above average, but she was assessed to have signifi cant diffi culties with reading. Her comprehension was poor, and she could not remember most of the content of what she read. We recommended that she continue with her trick of reading aloud, because her comprehension for what she heard was adequate. In addition, Alice was taught how to analyze her reading—that is, how to outline and take notes. She was even encouraged to audiotape her lectures and play them back to herself as she drove around in her car. Although Alice did not become an A student, she was able to graduate from the university, and she now works with young children who themselves have learning disabilities. 8.3 CASE OF JAMES James’s mother contacted us because he was disruptive at school and at work. James was 17 and attended the local high school. He had Down syndrome and was described as likable and, at times, mischievous. He enjoyed skiing, bike riding, and many other activities common among teenage boys. His desire to participate was a source of some conflict between him and his mother: He wanted to take the driver’s education course at school, which his mother felt would set him up for failure, and he had a girlfriend he wanted todate, a prospect that also caused his mother concern.School administrators complained because James didn’tparticipate in activities such as physical education, and atthe work site that was part of his school program he was oftensullen, sometimes lashing out at the supervisors. Theywere considering moving him to a program with more supervisionand less independence. James’s family had moved often during his youth, andthey experienced striking differences in the way each communityresponded to James and his intellectual disability. Insome school districts, he was immediately placed in classeswith other children his age and his teachers were providedwith additional assistance and consultation. In others, it wasjust as quickly recommended that he be taught separately. 126 CU IDOL SELF LEARNING MATERIAL (SLM)
Sometimes the school district had a special classroom in thelocal school for children with intellectual disability. Otherdistricts had programs in other towns, and James wouldhave to travel an hour to and from school each day. Everytime he was assessed in a new school, the evaluation wassimilar to earlier ones. He received scores on his IQ tests inthe range of 40 to 50, which placed him in the moderaterange of intellectual disability. Each school gave him thesame diagnosis: Down syndrome with moderate intellectualdisability. At each school, the teachers and other professionalswere competent and caring individuals who wanted thebest for James and his mother. Yet some believed that tolearn skills James needed a separate program with specializedstaff. Others felt they could not provide a program withspecialized staff. Still others felt they could provide a comparableeducation in a regular classroom and that to havepeers without disabilities would be an added benefit. In high school, James had several academic classes in aseparate classroom for children with learning problems, buthe participated in some classes, such as gym, with studentswho did not have intellectual disability. His current difficultiesin gym (not participating) and at work (being oppositional)were jeopardizing his placement in both programs. When I spoke with James’s mother, she expressed frustrationthat the work program was beneath him because hewas asked to do boring, repetitious work such as folding paper.James expressed a similar frustration, saying that hewas treated like a baby. He could communicate fairly wellwhen he wanted to, although he sometimes would becomeconfused about what he wanted to say and it was difficult tounderstand everything he tried to articulate. On observinghim at school and at work, and after speaking with histeachers, we realized that a common paradox had developed. James resisted work he thought was too easy. Histeachers interpreted his resistance to mean that the workwas too hard for him, and they gave him even simpler tasks.He resisted or protested more vigorously, and they respondedwith even more supervision and structure. 8.4 CASE OF ERIC “Eric. Eric? Eric!!” His teacher’s voice and the laughter of his classmates roused the boy from his reverie. Glancing at the book of the girl sitting next to him, he noticed that the class was pages ahead of him. He was supposed to be answering a question about the Declaration of Independence, but he had been lost in thought, wondering about what seats he and his father would have for the baseball game they’d be attending that evening. A tall, lanky 12-year-old, Eric had just begun seventh grade. His history teacher had already warned him about being late to class and not paying attention, but Eric just couldn’t seem to 127 CU IDOL SELF LEARNING MATERIAL (SLM)
get from one class to the next without stopping for drinks of water or to investigate an altercation between classmates. In class, he was rarely prepared to answer when the teacher called on him, and he usually forgot to write down the homework assignment. He already had a reputation among his peers as an “airhead.” Eric’s relief at the sound of the bell was quickly replaced by anxiety as he reached the playground for physical education. Despite his speed and physical strength, Eric was always picked last for baseball teams. His team was up to bat first, and Eric sat down to wait his turn. Absorbed in studying a pile of pebbles at his feet, he failed to notice his team’s third out and missed the change of innings. The other team had already come in from the outfield before Eric noticed that his team was out in the field—too late to avoid the irate yells of his P.E. teacher to take his place at third base. Resolved to watch for his chance to field the ball, Eric nonetheless found himself without his glove on when a sharply hit ball rocketed his way; he had taken it off to toss it in the air in the middle of the pitch. 8.5 CASE OF GINA Gina wasreferred to a community clinic because of overactive, inattentive,and disruptive behavior. Her hyperactivity and uninhibited behaviorcaused problems for her teacher and for other students. Shewould impulsively hit other children, knock things off their desks,erase material on the blackboard, and damage books and otherschool property. She seemed to be in perpetual motion, talking,moving about, and darting from one area of the classroom toanother. She demanded an inordinate amount of attention fromher parents and her teacher, and she was intensely jealous of otherchildren, including her own brother and sister. Despite her hyperactivebehavior, 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. 8.6 CASE OF DANNY Danny, a handsome 9-year-old boy, was referred to us becauseof his difficulties at school and at home. Danny had agreat deal of energy and loved playing most sports, especiallybaseball. Academically, his work was adequate, although histeacher reported that his performance was diminishing andshe believed he would do better if he paid more attention inclass. Danny rarely spent more than a few minutes on a taskwithout some interruption: He would get up out of his seat,rifl e through his desk, or constantly ask questions. His peerswere frustrated with him because he was equally impulsiveduring their interactions: He never finished a game, and insports he tried to play all positions simultaneously. 128 CU IDOL SELF LEARNING MATERIAL (SLM)
At home, Danny was considered a handful. His roomwas in a constant mess because he became engaged in agame or activity only to drop it and initiate something else.Danny’s parents reported that they often scolded him fornot carrying out some task, although the reason seemed tobe that he forgot what he was doing rather than that he deliberatelytried to defy them. They also said that, out oftheir own frustration, they sometimes grabbed him by theshoulders and yelled, “Slow down!” because his hyperactivitydrove them crazy. 8.7 CASE OF TOM Tom, a beautiful blond baby, was born with the umbilicalcord wrapped around his neck, so he had been without oxygenfor an unknown period. Nonetheless, he appeared to be ahealthy little boy. His mother later related that he was a goodbaby who rarely cried, although she was concerned he didn’tlike to be picked up and cuddled. His family became worriedabout his development when he was 2 years old and didn’ttalk (his older sister had at that age). They also noticed thathe didn’t play with other children; he spent most of his timealone, spinning plates on the fl oor, waving his hands in frontof his face, and lining up blocks in a certain order. The family’s pediatrician assured them that Tom wasjust developing at a different rate and would grow out of it.When, at age 3, Tom’s behavior persisted, his parentsconsulted a second pediatrician. Neurological examinationsrevealed nothing unusual but suggested, on the basis of Tom’s delay in learning such basic skills as talking and feeding himself, that he had mild intellectual disability. Tom’s mother did not accept this diagnosis, and overthe next few years she consulted numerous other professionalsand received numerous diagnoses (including childhoodschizophrenia, childhood psychosis, and developmentaldelay). By age 7, Tom still didn’t speak or play withother children, and he was developing aggressive and selfinjuriousbehaviors. His parents brought him to a clinic forchildren with severe disabilities. Here, Tom was diagnosedas having autism. The clinic specialists recommended a comprehensive educationalprogram of intensive behavioral intervention tohelp Tom with language and socialization and to counterhis increasing tendency to engage in tantrums. The workcontinued daily for approximately 10 years, both at theclinic and at home. During this time, Tom learned to sayonly three words: “soda,” “cookie,” and “Mama.” Socially,he appeared to like other people (especially adults), but hisinterest seemed to center on their ability to get him somethinghe wanted, such as a favorite food or drink. 129 CU IDOL SELF LEARNING MATERIAL (SLM)
If his surroundingswere changed in even a minor way, Tom becamedisruptive and violent to the point of hurting himself;to minimize his self-injurious behavior, the family took careto ensure that his surroundings stayed the same as much aspossible. However, no real progress was made toward eliminatinghis violent behavior, and as he grew bigger andstronger, he became increasingly difficult to work with; hehurt his mother physically on several occasions. With greatreluctance, she institutionalized Tom when he was 17. 8.8 CASE OF TIMMY Timmy, aged 6, was referred for assessment because his teachers found him unmanageable. Heas unable to sit still in school and concentrate on his school work. He left his chair frequentlyand ran around the classroom shouting. This was distracting for both his teachers andclassmates. Even with individual tuition he could not apply himself to his school work. He alsohad difficulties getting along with other children. They disliked him because he disrupted theirgames. He rarely waited for his turn and did not obey the rules. At home he was consistentlydisobedient and according to his father ran ‘like a motorboat’ from the time he got up until bedtime. He often climbed on furniture and routinely shouted rather than talked at an acceptablelevel. Timmy came from a well-functioning family. The parents had a very stable and satisfyingmarriage and together ran a successful business. Their daughter, Amanda, was a well-adjustedand academically able 8-year-old. The parents were careful not to favour the daughter over herbrother or to punish Timmy unduly for his constant disruption of his sister’s activities.However, there was a growing tension between each of the parents and Timmy. While they wereundoubtedly committed to him, they were also continually suppressing their growing irritationwith his frenetic activity, disobedience, shouting and school problems. Within the wider familythere were few resources that the parents could draw on to help them cope with Timmy. Thegrandparents, aunts and uncles lived in another county and so could not provide regular supportfor the parents. Furthermore, they were bewildered by Timmy’s condition, found it veryunpleasant, and had gradually reduced their contact with Timmy’s nuclear family since his birth. Psychometric evaluation showed that Timmy’s overall IQ was within the normal range but hewas highly distractible and had literacy and numeracy skills that were significantly below hisoverall ability level. On both the Parent Report Child Behaviour Checklist and the TeacherReport Form Child Behaviour Checklist Timmy’s scores were above the clinical cut- off for theattention problem subscale and the anxious/depressed subscale. Timmy perceived himself to be Timmy, aged 6, was referred for assessment because his teachers found him unmanageable. Hewas unable to sit still in school and concentrate on his school work. He left his chair frequentlyand ran around the classroom shouting. This was distracting for both his 130 CU IDOL SELF LEARNING MATERIAL (SLM)
teachers andclassmates. Even with individual tuition he could not apply himself to his school work. He alsohad difficulties getting along with other children. They disliked him because he disrupted theirgames. He rarely waited for his turn and did not obey the rules. At home he was consistentlydisobedient and according to his father ran ‘like a motorboat’ from the time he got up until bedtime. He often climbed on furniture and routinely shouted rather than talked at an acceptablelevel. Timmy came from a well-functioning family. The parents had a very stable and satisfying marriage and together ran a successful business. Their daughter, Amanda, was a well- adjusted and academically able 8-year-old. The parents were careful not to favour the daughter over her brother or to punish Timmy unduly for his constant disruption of his sister’s activities. However, there was a growing tension between each of the parents and Timmy. While they wereundoubtedly committed to him, they were also continually suppressing their growing irritationwith his frenetic activity, disobedience, shouting and school problems. Within the wider familythere were few resources that the parents could draw on to help them cope with Timmy. Thegrandparents, aunts and uncles lived in another county and so could not provide regular supportfor the parents. Furthermore, they were bewildered by Timmy’s condition, found it veryunpleasant, and had gradually reduced their contact with Timmy’s nuclear family since his birth. Psychometric evaluation showed that Timmy’s overall IQ was within the normal range but hewas highly distractible and had literacy and numeracy skills that were significantly below hisoverall ability level. On both the Parent Report Child Behaviour Checklist and the TeacherReport Form Child Behaviour Checklist Timmy’s scores were above the clinical cut- off for theattention problem subscale and the anxious/depressed subscale. Timmy perceived himself to be a failure. He believed that he could not do anything right at home or at school and he was sadthat the other children did not want to play with him. He believed that his teacher disliked himand doubted his parents’ love for him. There were a number of noteworthy features in Timmy’s developmental history. He hadsuffered anoxia at birth and febrile convulsions in infancy. He had also had episodes of projectilevomiting. His high activity level and demandingness were present from birth. He also displayeda difficult temperament, showing little regularity in feeding or sleeping and intense negativeemotions to new stimuli; and he was slow to soothe following an intense experience of negativeemotion. Timmy was a 6-year-old boy with home- and school-based problems of hyperactivity,impulsivity and distractibility of sufficient severity to warrant a diagnosis of 131 CU IDOL SELF LEARNING MATERIAL (SLM)
attention deficithyperactivity disorder (ADHD). Possible predisposing factors included anoxia at birth, subtleneurological damage due to febrile convulsions in infancy, and a difficult temperament InTimmy’s case ADHD had led to academic attainment difficulties; peer-relationship problems;and tension within the family. This wider constellation of difficulties underpinned Timmy’sdiminishing self-esteem, which in turn exacerbated his problems with attainment, peerrelationships and family relationships. The absence of an extended family support system for theparents to help them deal with Timmy’s difficulties was also a possible maintaining factor. Important protective factors in this case were the commitment of the parents to resolving theproblem and supporting Timmy and the stability of Timmy’s nuclear family. Treatment in this case involved both psychosocial and pharmacological intervention. The psychosocial intervention included parent and teacher education about ADHD; behaviouralparent training; self-instructional training for the child; a classroom-based behaviouralprogramme; and provision of periodic relief care/holidays with specially trained foster parents.Timmy was also placed on methylphenidate. 8.9 SUMMARY • Case study refer to an indepth investigation of an individual case or person. • In clinical settings, case studies provide us valuabel inofrmation about the disorder, it’s progression, symptoms and impact on the person anf the family. • Case studies help the students to understand the disorders properly. • They give us examples of how symptoms manifest in real life situation. • Case studies also help us to plan interventions better. 8.10 KEYWORDS • Abnormal behavior: Behavior that involves a combination of personal distress, psychological dysfunction, deviance from social norms, dangerousness to self and others, and costliness to society. • Mental retardation: The condition of having an IQ measured as below 70 to 75 and significant delays or lacks in at least two areas of adaptive skills. Mental retardation is present from childhood. • Learning disabilities: Learning disabilities are disorders that affect the ability to understand or use spoken or written language, do mathematical calculations, coordinate movements, or direct attention. 132 CU IDOL SELF LEARNING MATERIAL (SLM)
• ADHD: ADHD, or attention-deficit hyperactivity disorder, is a behavioral condition that makes focusing on everyday requests and routines challenging. 8.11 LEARNING ACTIVITY 1. With the help of any one cases explain ow the symptoms of ADHD make schooling difficult? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. Discuss how the impact of mental retardation and learning disability is different? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 8.12 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What were the difficulties Alice had because of learning disorder? 2. Why did Eric’s mother felt he would not clear the driving test? 3. What was the diagnosis of Eric? 4. What was Tom institutionalized for? 5. Why was Danny unable to cope in school? Long Questions 1. Explain the difficulties faced by Alice and how she was helped to overcome them? 2. What were the challenges faced by James in the rehabilitation? 3. What is similarity between Eric nad Gina? 4. What was the plan of intervention planed for Tom? 5. Explain the assessment conducted in case of Timmy B. Multiple Choice Questions 1. Behavioral disorders may involve: 133 a. Inattention b. Hyperactivity CU IDOL SELF LEARNING MATERIAL (SLM)
c. Criminal Activity d. All of these 2. Children with this form of ADHD cannot. a. Pay attention in class b. Sit still c. All of these d. Complete a task 3. Also known as behavior modification. a. Behavioral therapy b. Cognitive Behavioral therapy c. Cognitive Therapy d. Medication Therapy 4. Alice was suffering from. a. Learning disorderr b. Disruptive Mood Dysregulation Disorder c. Social Communication Disorder d. Child Mental Disorder 5. The cause of Tom’s down syndrom could be. a. Trauma during birth b. Socio – economic causes c. Lack of oxygen during birth d. Mental Disorder in family Answers 1-(d), 2-(c), 3-(a), 4-(b), 5-(c) 8.13 REFERENCES Textbook • Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. • American PsychiatricAssociation (2000).Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC:American Psychiatric Publishing, Inc.. 134 CU IDOL SELF LEARNING MATERIAL (SLM)
• Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. • Armstrong TD, Costello EJ (2002), Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. J Consult Clin Psychol. · • Banaschewski T, Brandeis D, Heinrich H, Albrecht B, Brunner E, Rothenberger A (2003), Association of ADHD and conduct disorder - brain electrical evidence for the existence of a distinct subtype. J Child Psychol Psychiatr • .Bannerje T (1997), Psychiatric morbidity among rural primary school children in West Bengal Indian J Psychiat • Barkley RA(1987). Defiant children: a clinician’s manual for parent training. NewYork: Guilford. References: • Campbell SB (2002), Behavior Problems in Preschool Children: Clinical and Developmental Issues. New York: Guilford. • Campbell SB, Shaw DS, Gilliom M (2000), Early externalizing behavior problems: toddlers and preschoolers at risk for later maladjustment. Dev Psychopathol. • Cantwell DP, Swanson J, Connor DF (1997), Case study: adverse response to clonidine. J Am Acad Child Adolesc Psychiatry • Carey G, DiLalla D (1994), Personality and psychopathology: genetic perspectives. J Abnormal Psychol. 135 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT –9 DISORDERS: OPPOSITIONAL DEFIANT DISORDER – PART I Structure 9.0LearningObjectives 9.1 Introduction 9.2 Oppositional Defiant Disorder 9.3 Dsm Criteria 9.4 ICD-10 9.5 Summary 9.6 Keywords 9.7 Learning Activity 9.8 Unit End Questions 9.9 References 9.0 LEARNINGOBJECTIVES After learning this unit, you will be able to: • Explain the concept of disruptive behaviour disorder • Explain the concept of oppositional defiant disorder • Describe the criteria used for diagnosing oppositional defiant disorder under DSM and ICD – 10 ` 9.1 INTRODUCTION Disruptive behavior disorders are among the easiest to identify of all coexisting conditions because they involve behaviours that are readily seen such as temper tantrums, physical aggression such as attacking other children, excessive argumentativeness, stealing, and other forms of defiance or resistance to authority. These disorders, which include ODD and CD, 136 CU IDOL SELF LEARNING MATERIAL (SLM)
often first attract notice when they interfere with school performance or family and peer relationships, and frequently intensify over time. Behaviours typical of disruptive behavior disorders can closely resemble ADHD— particularly where impulsivity and hyperactivity are involved—but ADHD, ODD, and CD are considered separate conditions that can occur independently. About one third of all children with ADHD have coexisting ODD, and up to one quarter have coexisting CD. Children with both conditions tend to have more difficult lives than those with ADHD alone because their defiant behavior leads to so many conflicts with adults and others with whom they interact. Early identification and treatment may, however, increase the chances that your child can learn to control these behaviours. Oppositional Defiant Disorder Many children with ADHD display oppositional behaviours at times. Oppositional defiant disorder is defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as including persistent symptoms of “negativistic, defiant, disobedient, and hostile behaviours toward authority figures.” A child with ODD may argue frequently with adults; lose his temper easily; refuse to follow rules; blame others for his own mistakes; deliberately annoy others; and otherwise behave in angry, resentful, and vindictive ways. He is likely to encounter frequent social conflicts and disciplinary situations at school. In many cases, particularly without early diagnosis and treatment, these symptoms worsen over time—sometimes becoming severe enough to eventually lead to a diagnosis of conduct disorder. Conduct Disorder Conduct disorder is a more extreme condition than ODD. Defined in the DSM-IV as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate social rules are violated,” CD may involve serious aggression toward people or the hurting of animals, deliberate destruction of property (vandalism), stealing, running away from home, skipping school, or otherwise trying to break some of the major rules of society without getting caught. Many children with CD were or could have been diagnosed with ODD at an earlier age—particularly those who were physically aggressive when they were younger. As the CD symptoms become evident, these children usually retain their ODD symptoms (argumentativeness, resistance, etc) as well. This cluster of behaviours, combined with the impulsiveness and hyperactivity of ADHD, sometimes causes these children to be viewed as delinquents, and they are likely to be suspended from school and have more police contact than children with ADHD alone or ADHD with ODD. 137 CU IDOL SELF LEARNING MATERIAL (SLM)
Children with ADHD whose CD symptoms started at an early age also tend to fare more poorly in adulthood than those with ADHD alone or ADHD with ODD—particularly in the areas of delinquency, illegal behavior, and substance abuse. ODD and CD: What to Look For A child with ADHD and a coexisting disruptive behavior disorder is likely to be similar to children with ADHD alone in terms of intelligence, medical history, and neurological development. He is probably no more impulsive than children with ADHD alone, although if he has conduct disorder, his teachers or other adults may misinterpret his aggressive behavior as ADHD-type impulsiveness. (Attention-deficit/hyperactivity disorder behavior without CD, however, does not typically involve this level of aggression.) A child with ADHD and CD does have a greater chance of experiencing learning disabilities such as reading disorders and verbal impairment. But what distinguishes children with ODD and CD most from children with ADHD alone is their defiant, resistant, even (in the case of CD) aggressive, cruel, or delinquent, behavior. Other indicators to look for include • Relatives with ADHD/ODD, ADHD/CD, depressive disorder or anxiety disorder. A child with family members with ADHD/ODD or ADHD/CD should be watched for ADHD/CD as well. Chances of developing CD are also greater if family members have experienced depressive, anxiety, or learning disorders. • Stress or conflict in the family. Divorce, separation, substance abuse, parental criminal activity, or serious conflicts within the family are quite common among children with ADHD and coexisting ODD or CD. • Poor or no positive response to the behavior therapy techniques at home and at school. If your child defies your instructions, violates time-out procedures, and otherwise refuses to cooperate with your use of appropriate behavior therapy techniques, and his aggressive behavior continues unabated, he should be evaluated for coexisting ODD or CD. 9.2 OPPOSITIONAL DEFIANT DISORDER Even the best-behaved children can be difficult and challenging at times. But if your child or teenager has a frequent and persistent pattern of anger, irritability, arguing, defiance or vindictiveness toward you and other authority figures, he or she may have oppositional defiant disorder (ODD). As a parent, you don't have to go it alone in trying to manage a child with ODD. Doctors, mental health professionals and child development experts can help. 138 CU IDOL SELF LEARNING MATERIAL (SLM)
Behavioral treatment of ODD involves learning skills to help build positive family interactions and to manage problematic behaviours. Additional therapy, and possibly medications, may be needed to treat related mental health disorders. Symptoms Sometimes it's difficult to recognize the difference between a strong-willed or emotional child and one with oppositional defiant disorder. It's normal to exhibit oppositional behavior at certain stages of a child's development. Signs of ODD generally begin during preschool years. Sometimes ODD may develop later, but almost always before the early teen years. These behaviours cause significant impairment with family, social activities, school, and work. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing ODD. The DSM-5 criteria include emotional and behavioral symptoms that last at least six months. Angry and irritable mood: • Often and easily loses temper • Is frequently touchy and easily annoyed by others • Is often angry and resentful Argumentative and defiant behavior: • Often argues with adults or people in authority • Often actively defies or refuses to comply with adults' requests or rules • Often deliberately annoys or upsets people • Often blames others for his or her mistakes or misbehaviour Vindictiveness: • Is often spiteful or vindictive • Has shown spiteful or vindictive behavior at least twice in the past six months ODD can vary in severity: • Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers. • Moderate. Some symptoms occur in at least two settings. • Severe. Some symptoms occur in three or more settings. 139 CU IDOL SELF LEARNING MATERIAL (SLM)
For some children, symptoms may first be seen only at home, but with time extend to other settings, such as school and with friends. Causes There's no known clear cause of oppositional defiant disorder. Contributing causes may be a combination of inherited and environmental factors, including: • Genetics — a child's natural disposition or temperament and possibly neurobiological differences in the way nerves and the brain function • Environment — problems with parenting that may involve a lack of supervision, inconsistent or harsh discipline, or abuse or neglect Risk factors Oppositional defiant disorder is a complex problem. Possible risk factors for ODD include: • Temperament — a child who has a temperament that includes difficulty regulating emotions, such as being highly emotionally reactive to situations or having trouble tolerating frustration • Parenting issues — a child who experiences abuse or neglect, harsh or inconsistent discipline, or a lack of parental supervision • Other family issues — a child who lives with parent or family discord or has a parent with a mental health or substance use disorder • Environment — oppositional and defiant behaviours can be strengthened and reinforced through attention from peers and inconsistent discipline from other authority figures, such as teachers Complications Children and teenagers with oppositional defiant disorder may have trouble at home with parents and siblings, in school with teachers, and at work with supervisors and other authority figures. Children with ODD may struggle to make and keep friends and relationships. ODD may lead to problems such as: • Poor school and work performance • Antisocial behavior • Impulse control problems 140 CU IDOL SELF LEARNING MATERIAL (SLM)
• Substance use disorder • Suicide Many children and teens with ODD also have other mental health disorders, such as: • Attention-deficit/hyperactivity disorder (ADHD) • Conduct disorder • Depression • Anxiety • Learning and communication disorders Treating these other mental health disorders may help improve ODD symptoms. And it may be difficult to treat ODD if these other disorders are not evaluated and treated appropriately. Prevention There's no guaranteed way to prevent oppositional defiant disorder. However, positive parenting and early treatment can help improve behavior and prevent the situation from getting worse. The earlier that ODD can be managed, the better. Treatment can help restore your child's self-esteem and rebuild a positive relationship between you and your child. Your child's relationships with other important adults in his or her life — such as teachers and care providers — also will benefit from early treatment. Best practices for managing disruptive behavior Effective prevention Establishing norms helps prevent disruptive behavior and allows you to react effectively in the moment. In addition to using your syllabus to set academic expectations, you can also utilize it to create classroom behavioral expectations. The factors that constitute appropriate and inappropriate behavior are often dependent on the nature of class and faculty comfort level, and can vary widely from lectures to labs and across content areas. Faculty have found it helpful to: • Outline both productive and disruptive types of behavior. 141 • Outline the process by which disruptive behavior will be addressed. CU IDOL SELF LEARNING MATERIAL (SLM)
• Outline consequences for ongoing disruptive behavior. • Verbally address classroom expectations regarding behavior on the first day of class. It is especially effective to talk about behavior you want to see, as well as the type that’s disruptive. • Model the type of behavior you expect from your class. How to respond to a disruption, in the moment Your direct intervention will work for a majority of situations; however, some students and situations are ongoing and will require additional consultation and follow up. The departments and campus partners within Student Life are available to work with you on handling disruptive situations. It is important to remember that if the disruption causes immediate concern for personal safety, do not hesitate to call UWPD. What to do Stay calm and listen to student concerns – identifying the catalyst for disruption can help you address the situation in the moment or in a later meeting. • Be steady, consistent and firm. • Acknowledge the feelings of the individual. • Remember that disruptive behavior is often caused by stress or frustration. • Address the disruption individually, directly and immediately. • Be specific about the behavior that is disruptive and set limits. • Remove the student from that class session if the student does not comply with your actions. If the student does not leave after being asked to do so, you can call UWPD for backup. • Ask the student to see you after class to address the disruption, explore the causes of the incident and discuss appropriate behavior. • Pay attention to warning signs that the situation is nearing escalation toward violence. • Be aware of your own limitations – operate within your own scope of comfort: • Faculty can contact UWPD and have the student removed from class. • Faculty can bring class to an end for the day. • Faculty can seek out additional resources and coaching to handle the disruptive student. What to avoid • Do not allow the behavior to continue. 142 CU IDOL SELF LEARNING MATERIAL (SLM)
• Avoid making it a class issue – address only the student who is causing the disruption. • Avoid an argument or shouting match. • Do not blame or ridicule the student, or use sarcasm. • Do not touch the students Suggestions for intervening in a disruption • Keep your focus on the student. Rather than say, “Class, we all know that talking during lecture is disruptive,” say, “Jane, you’re talking during class is disrupting the lecture and I need to ask you to stop.” • Be clear about the behavior. If the student is talking out of turn, tell them. Rather than ask, “Do you have a question?” say, “Jane, now is not the time for discussion. There will be an opportunity for questions and debate at the end of the lecture.” • Nip the situation in the bud, referring to the syllabus regarding expectation and behavior. “Jane, you will note that in the syllabus, talking during lecture is considered disruptive behavior. If I need to ask you to stop talking again, I will need to ask you to leave.” • Distress is often the cause of a disruption. It is important to recognize the stress while still addressing the behavior. Rather than say, “John, you are clearly emotional right now and you need to stop arguing,” say, “John, I can see that this topic has you upset; however, we need to bring this debate to a close.” • If you need to ask the student to leave, do so clearly and directly. Rather than say, “Get out! Go! Get out of here!” say, “John, your behavior has exceeded what is acceptable for this class and it is time for you to leave. I will be in contact with you via email to discuss future class sessions.” At this point, it is a good idea to pause class until the student exits the room. What to do following a disruption While many disruptions are minor and can be managed in the moment, it can be beneficial both to document the incident and follow up with the student. Documenting what you experienced and the steps you took will be helpful if you need to pursue a violation of the student conduct code. Clear communication with the student helps to set expectations and prevent further disruption. The following are suggestions to consider following an incident: • Document the details about the incident, including the time/date/location, the behavior of the student, the actions you took and how the situation was resolved in the moment. • For minor disruptions, an email can serve as both a tool to remedy behavior and to document the incident. In the email, you should include the observed behavior, your expectations for class and how they differ from the observed behavior, and the consequences of continued disruption. 143 CU IDOL SELF LEARNING MATERIAL (SLM)
• If the disruption is more egregious or a behavior is ongoing, you should contact your departmental leadership for appropriate next steps. Keeping them in the loop regarding behavior of concern is always recommended. • In some cases, a meeting with the student is required to discuss the behavior in more depth, explore appropriate solutions and set clear guidelines and consequences. Often, you can find support for these meetings within your department or with Community Standards and Student Conduct. • If additional support is necessary, please contact Community Standards and Student 9.3 DSM CRITERIA Highlights and Changes from DSM-IV TR to DSM 5 The chapter on disruptive, impulse- control, and conduct disorders is new to DSM-5. It brings together disorders that were previously included in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse-control, and conduct disorders) and the chapter “Impulse-Control Disorders Not Otherwise Specified” (i.e., intermittent explosive disorder, pyromania, and kleptomania). These disorders are all characterized by problems in emotional and behavioral self-control. Of note, ADHD is frequently comorbid with the disorders in this chapter but is now listed in DSM 5 with the neurodevelopmental disorders. It had previously (DSM-IV TR) been considered within the DBDs. It will not be addressed as a primary diagnosis in this guideline because it is covered separately and may be accessed at http://psychiatry.uams.edu/PsychTLC). Four refinements have been made to the criteria for oppositional defiant disorder. First, symptoms are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. This change highlights that the disorder reflects both emotional and behavioral symptomatology. Second, the exclusion criterion for conduct disorder has been removed. Third, given that many behaviours associated with symptoms of oppositional defiant disorder occur commonly in normally developing children and adolescents, a note has been added to the criteria to provide guidance on the frequency typically needed for a behavior to be considered symptomatic of the disorder. Fourth, a severity rating has been added to the criteria to reflect research showing that the degree of pervasiveness of symptoms across settings is an important indicator of severity. 144 CU IDOL SELF LEARNING MATERIAL (SLM)
Figure 9.1 Symptoms & Clinical Features of Disruptive Behaviour Disorders Early Warning Signs • Irritable temperament • Inattentiveness • Impulsivity • Defiance of adults • Poor social skills • Lack of school readiness • Coercive interactive style • Aggression toward peers • Lack of problem-solving skills Diagnostic Criteria Oppositional Defiant Disorder • Loses temper 145 • Angry • Arguing with adults • Disobedience • Easily annoyed • Spiteful CU IDOL SELF LEARNING MATERIAL (SLM)
• Blames others for mistakes • Deliberately annoys others The principal subdivision to be made in ODD is between the variety that appears to progress to CD and the variety that does not. Greater severity and early onset of oppositional behavior, frequent physical fighting, parental substance abuse and low socio-economic status appear to increase the risk of progression to more severe antisocial behaviours observed in CD (Dulcan & Loeber, 1995) Conduct Disorder Exhibits a pattern of behavior that violates the rights of others or disregards age-specific social norms • Deliberately break rules • Aggressive toward people or animals • Destructive of property • Lying and theft Violation of rules For example skipping school and substance use As noted in the following diagram, the possibility of progression is present in Disruptive Behavior Disorders. However, there are also protective factors that can mitigate the escalation. Protective factors would include • Late onset • Early assessment • Effective treatment • The absence of co-occurring disorders • Negative family history for DBD 146 CU IDOL SELF LEARNING MATERIAL (SLM)
Table 9.1 Differential Diagnosis Figure 9.2 Comorbid Conditions for Disruptive Behaviour Disorders 147 CU IDOL SELF LEARNING MATERIAL (SLM)
9.4 ICD-10 ICD-10-CM Codes - Mental, Behavioral and Neurodevelopmental disorders F01-F99 Mental, Behavioral and Neurodevelopmental disorders F01-F99 Type 2 Excludes • symptoms, signs, and abnormal clinical laboratory findings, not elsewhere classified (R00- R99) Includes • Disorders of psychological development • Behavioural and emotional disorders with onset usually occurring in childhood and adolescence Note: • Codes within categories F90-F98 may be used regardless of the age of a patient. These disorders generally have onset within the childhood or adolescent years, but may continue throughout life or not be diagnosed until adulthood • F90 Attention-deficit hyperactivity disorder... • F91.0 Conduct disorder confined to family context • F91.1 Conduct disorder, childhood-onset type • F91.2 Conduct disorder, adolescent-onset type • F91.3 Oppositional defiant disorder • F91.8 Other conduct disorders • F91.9 Conduct disorder, unspecified • F93 Emotional disorders with onset specific to childhood • F93.0 Separation anxiety disorder of childhood • F93.8 Other childhood emotional disorders • F93.9 Childhood emotional disorder, unspecified • F94 Disorders of social functioning with onset specific to childhood and adolescence • F94.0 Selective mutism • F94.1 Reactive attachment disorder of childhood • F94.2 Disinhibited attachment disorder of childhood • F94.8 Other childhood disorders of social functioning • F94.9 Childhood disorder of social functioning, unspecified • F95 Tic disorder 148 CU IDOL SELF LEARNING MATERIAL (SLM)
• F95.0 Transient tic disorder • F95.1 Chronic motor or vocal tic disorder • F95.2 Tourette's disorder • F95.8 Other tic disorders • F95.9 Tic disorder, unspecified • F98 Other behavioural and emotional disorders with onset usually occurring in childhood and adolescence • F98.0 Enuresis not due to a substance or known physiological condition • F98.1 Encopresis not due to a substance or known physiological condition • F98.2 Other feeding disorders of infancy and childhood • F98.21 Rumination disorder of infancy • F98.29 Other feeding disorders of infancy and early childhood • F98.3 Pica of infancy and childhood • F98.4 Stereotyped movement disorders • F98.5 Adult onset fluency disorder • F98.8 Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence • F98.9 Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence 9.5 SUMMARY • A related but less well understood externalizing disorder in the DSM-IV-TR is oppositional defiant disorder (ODD). • There is some debate as to whether ODD is distinct from conduct disorder, a precursor to it, or an earlier and milder manifestation of it. ODD is diagnosed if a child does not meet the criteria for conduct disorder—most especially, extreme physical aggressiveness—but exhibits such behaviors as losing his or her temper, arguing with adults, repeatedly refusing to comply with requests from adults, deliberately doing things to annoy others, and being angry, spiteful, touchy, or vindictive. • Commonly comorbid with ODD are ADHD, learning disorders, and communication disorders, but ODD is different from ADHD in that the defiant behavior is not thought to arise from attentional deficits or sheer impulsiveness. • One manifestation of difference is that children with ODD are more deliberate in their unruly behavior than children with ADHD. Although conduct disorder is three to four times more common among boys than among girls, research suggests that boys are only slightly more likely to have ODD, and some studies find no difference in 149 CU IDOL SELF LEARNING MATERIAL (SLM)
prevalence rates for ODD between boys and girls. Because less is known about ODD, we will focus here on the more serious diagnosis of conduct disorder. 9.6 KEYWORDS • Oppositional defiant disorder - characterized by a repeating pattern of negative, hostile, and defiant behaviors, such as temper outbursts, being argumentative, defying rules, blaming, being angry and vindictive. This pattern usually lasts longer than six months, or beyond what is considered within the bounds of normal childhood stage development. • Conduct Disorder (CD): Conduct Disorder (CD) is characterized by callous disregard for and aggression toward others, from pushing, hitting and biting in early childhood to bullying, cruelty and violence in adolescence. • Deceitfulness: The act or practice of deceiving: cunning, deceit, deception, double- dealing, duplicity, guile, shiftiness. • Bullying: Bullying the behaviour of a person who hurts or frightens someone smaller or less powerful, often forcing that person to do something they do not want to do: Bullying is a problem in many schools. • Vindictiveness: Vindictiveness is a strong desire to get back at someone. People who hold grudges and seek revenge are full of vindictiven 9.7 LEARNING ACTIVITY 1. What is difference between Oppositional Defiant Disorder and Conduct Disorder? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. Do you think with the increase in exposure to violence from a young age, more children will be diagnosed with behaviour disorders? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 9.8 UNIT END QUESTIONS A. Descriptive Questions Short Questions 150 CU IDOL SELF LEARNING MATERIAL (SLM)
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