By Amanda Turner

S E R I E S C O N S U L T A N T Anne S. Walters, Ph.D. Emma Pendleton Bradley Hospital Warren Alpert Medical School of Brown University

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Foreword: Dr. Anne S. Walters, Ph.D.. ......................................... 6 Chapter 1: Introduction to Disruptive Disorders. ....................... 11 Chapter 2: History of Oppositional Defiant Disorder................... 35 Chapter 3: Understanding the Causes of ODD. ........................... 47 Chapter 4: Treatments for ODD. ............................................... 61 Chapter 5: How ODD Affects Adults........................................... 79 Chapter 6: How Families Cope with ODD. .................................. 89 Chapter Notes. ..................................................................... 102 Series Glossary of Key Terms. ................................................ 104 Further Reading. .................................................................. 106 Internet Resources................................................................ 107 Organizations to Contact....................................................... 108 Index................................................................................... 109 Author’s Biography / Credits................................................. 112 CONTENTS KEY ICONS TO LOOK FOR: Words to Understand: These words with their easy-to-understand definitions will increase the reader’s understanding of the text while building vocabulary skills. Sidebars: This boxed material within the main text allows readers to build knowledge, gain insights, explore possibilities, and broaden their perspectives by weaving together additional information to provide realistic and holistic perspectives. Educational videos: Readers can view videos by scanning our QR codes, providing them with additional educational content to supplement the text. Examples include news coverage, moments in history, speeches, iconic sports moments, and much more! Text-Dependent Questions: These questions send the reader back to the text for more careful attention to the evidence presented there. Research Projects: Readers are pointed toward areas of further inquiry connected to each chapter. Suggestions are provided for projects that encourage deeper research and analysis. Series Glossary of Key Terms: This back-of-the-book glossary contains terminology used throughout this series. Words found here increase the reader’s ability to read and comprehend higher-level books and articles in this field.


Dr. Anne S. Walters, Ph.D.

Almost one in seven children and adolescents in the United States has a diagnosable mental illness, according to the National Institute of Mental Health (NIMH), the leading federal agency for research on mental disorders. That’s more than the number of children and adolescents suffering from cancer, AIDS, and diabetes combined. NIMH

research has found that almost 50 percent of these young people will experience an episode of mental illness before the age of eighteen. The rate of mental illness is even higher among young adults between the ages of eighteen and twenty-five. This is not a uniquely American problem, however. The World Health Organization (WHO) reports that mental disorders are the leading cause of disability among young people in all regions of the world. The most common behavioral health diagnoses in children include


attention deficit hyperactivity disorder (ADHD), behavior problems, anxiety, and depression. Some of these conditions commonly occur together. For example, about three in four children (73.8 percent) between the ages of three and seventeen who have been diagnosed with depression also suffer from anxiety, and almost one in two (47.2 percent) exhibit behavioral problems, according to the Centers for Disease Control and Prevention. What do these numbers mean? To start, it means that mental illness is very common. Most of you reading this will have at least one friend or family member who either is currently struggling or has struggled in the past with a psychiatric illness. That number may even include you and may mean that you have symptoms of both anxiety and depression. In addition, mental illness is becoming more common. Suicide rates have increased in children and adolescents over the past ten years, and this is a major concern at present for professionals in the behavioral health field. No one is sure what has caused these increases, though some speculate it is related to “cultural trends.” A combination of factors such as social media and technology advances or the opioid crisis may all play contributing roles. Other professionals have wondered about how violence in our schools might impact youth mental health, and still others have pointed to the potential effects of decreased sleep on these illnesses.


Despite there being more widespread information about the prevalence of mental health issues for children and adolescents, only slightly more than half of these children receive treatment. What gets in the way? One of the barriers to seeking treatment is the fear that others will find out. Children, adolescents, and even parents fear the stigma of being identified as having a mental illness. Despite progress in the diagnosis and treatment of these illnesses, the stigma that surrounds mental illness is still very profound, even today. Parents fear that their children will experience shame. As long as this stigma exists, it affects the likelihood that children or their families will seek help. Other barriers include doctor and hospital wait lists, concern about medical expense, a shortage of available mental health providers, and lack of knowledge about treatment options. Some of the movements toward reducing stigma have been helpful in this regard. Notable examples are actress Glenn Close and her foundation aimed at reducing the stigma for those with bipolar disorder, or Olympic athlete Michael Phelps speaking out about his own depression. The good news in all of this is that in recent years, evidence-based treatment has become available. The term “evidence based” refers to treatment that has been tested via research and proven to be effective for various types of mental illness. For example, we know that a form of treatment called “Coping Cat” utilizes a cognitive behavioral form of treatment that is effective for childhood


anxiety, and that effectiveness is improved with the use of certain medications as well. Cognitive behavioral therapy (CBT) targets the way that we negatively interpret or perceive situations, and teaches us to “restructure” those thoughts, leading to different feelings and experiences. We know CBT is helpful because researchers have performed studies comparing patients who get this form of treatment with patients that receive other forms of treatment. Our readers will learn more about all these topics in the volumes ahead. We hope that having more information will help you to combat the stigma that surrounds mental illness, and therefore reduce the length of time it takes a child and family to seek treatment. Our hope is that this series will spark conversation and provide important information for children, parents, and school personnel about the various diagnoses that are most common in childhood and adolescence. With this series, we hope you will understand much more about mental illnesses, what is involved, and what to do to help those who might be suffering like family, friends, or even you.



co-morbidity: a disorder that exists alongside a different distinct disorder delinquent: referring to behavior by a young person that is criminal or inappropriate in nature psychiatrist: a mental health doctor who provides therapy and prescribes medication psychologist: a mental health doctor who provides therapy but does not prescribe medication vindictiveness: an intent to harm another person, often to get revenge


1 chapter

Introduction to DISRUPTIVE Disorders

Case Study: Wyatt A few weeks before he turned five, Wyatt began to act out. He talked back to adults who made simple requests. He began to have trouble following the rules at preschool. Wyatt’s teachers told his parents that other students in his class complained that Wyatt was bothering them. At first, his parents chalked it up to Wyatt’s desire to test the limits of the rules at home and in the classroom. They weren’t sure whether there was a real problem. Soon, Wyatt’s behaviors became even worse. Wyatt became unkind to others, ruining a teacher’s belongings when he felt the teacher had wronged him. His refusal to follow rules transitioned into tantrums that lasted for hours. Wyatt’s tantrums disrupted his entire family. He became violent with his mother and father. The household lived in constant fear of Wyatt’s next outburst. It became hard for anyone to relax at home. It was difficult to plan family activities that included Wyatt.


It is normal for young children to act out at times, but in extreme cases such behavior could be a sign of a disruptive, impulse-control, or conduct disorder.

What Are Disruptive, Impulse- Control, and Conduct Disorders? Eventually, a professional diagnosed Wyatt with a type of disorder in the category of disruptive, impulse-control, and conduct disorders. These severe mental disorders are usually diagnosed in childhood or the teen years, and children who have them usually begin exhibiting a repetitive and persistent pattern of negative or “antisocial” behaviors. With certain types of these disorders, children may show aggression toward others, much like in Wyatt’s case. These children often push, hit, or bite others or otherwise exhibit cruelty or violence in their adolescent years. Teens with conduct disorders, for example, tease and bully others, pick fights, or often steal or vandalize. With other disorders in this category, people may set fires, hurt animals or become physically violent.


Behavioral Disorders: Disruptive, Impulse Control, and Conduct Disorders

In the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) , there was a significant update to this class of disorders, which the DSM-5 outlines as disruptive, impulse-control, and conduct disorders. Many of these disorders were previously in other categories, but the DSM-5 combined different disorders together that involve problems with self control, impulse control, and emotions. The majority of these disorders first appear in infancy, childhood, or adolescence, and include: • oppositional defiant disorder (ODD) • conduct disorder • intermittent explosive disorder • pyromania • kleptomania • antisocial personality disorder (which is also considered personality disorder)

An impulse control disorder is a condition in which a person has trouble controlling his or her emotions or behaviors.


Introduction to Disruptive Disorders

Over 50 million people around the world are affected by these disorders, many of which are characterized by a disregard for the feelings and rights of other people. Aggression and causing harm are gratifying to those who have these disorders. Adults with these disorders can lie, steal, and cheat. Rule-breaking is common with these disorders and adults may even be aggressive. The disorders are harder to detect in children. All kids from time to time act out; it is part of normal behavior. However, children with conduct disorders show these behaviors in a consistent and persistent pattern. All disorders in this category are described, but for the purposes of this book, we will focus mainly on one disruptive disorder called oppositional defiant disorder. Wyatt’s story is fairly descriptive for children with oppositional defiant disorder or ODD. According to the DSM-5 , oppositional defiant disorder occurs when a person (usually a child) shows an argumentative or defiant pattern of behavior, an angry or irritable mood, and/or a pattern of vindictiveness for a period of six months or longer. What Is Oppositional Defiant Disorder? It can be hard to tell the difference between normal acting out and oppositional defiant disorder. “Many children tend to disobey, argue with parents, or defy authority,” explains an overview by Stanford Children’s Health. “They may often behave this way when they are tired, hungry, or upset. But in children and teens with ODD, these symptoms happen more often and also interfere with learning and school adjustment. In some cases, the symptoms disrupt the child’s relationships with others.” 1 The Diagnostic and Statistical Manual identifies three characteristics of oppositional defiant disorder: anger/irritable mood; argumentative and defiant behaviors; and vindictiveness.


Behavioral Disorders: Disruptive, Impulse Control, and Conduct Disorders

Parents and even professionals sometimes have difficulty determining whether a child’s behavior is just acting out or whether it is a true disorder.

A child who loses his or her temper often, is touchy or easily annoyed, or regularly seems angry and resentful would fall into the category of angry/irritable mood. Argumentative or defiant behavior would be seen in someone who argues with authority figures or adults, actively defies rules or refuses to comply with orders from authority figures, deliberately annoys other people, or blames others for his or her mistakes or misbehavior. According to the DSM-5, someone who has been spiteful or has shown a strong and unreasonable desire for revenge at least twice during the previous six-month period would be considered vindictive. Children with oppositional defiant disorder often express their disorder in one of these three categories. For example, one child may be angry and irritable, while another may predominantly exhibit vindictiveness towards classmates. Both children can have ODD, so the DSM-5 subtypes allow for individual differences. A person’s


Introduction to Disruptive Disorders

A child suffering from oppositional defiant disorder (ODD) may exhibit extreme difficulty interacting with parents and siblings at home, or with teachers in school.

environment, parenting styles, and learned history all contribute to how ODD is expressed differently in different individuals. In fact, it is rare to see two people with ODD acting in the same exact way. The DSM-5 also provides mental health professionals with a severity rating for oppositional defiant disorder. Classifying a person’s ODD as mild, moderate, or severe allows for a more individualized diagnosis. Conduct Disorder According to the American Academy of Child and Adolescent Psychiatry, conduct disorder (CD) refers to a group of repetitive and persistent behavioral and emotional problems in youngsters. Children and adolescents with this disorder have great difficulty


Behavioral Disorders: Disruptive, Impulse Control, and Conduct Disorders

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