**Braeden has ADHD combined type with Oppositional/Defiant and Aggressive features . As of yet, he hasn't met enough of the criteria for Oppositional Defiant Disorder or Conduct/Aggressive Disorder - explained below**
There are three childhood disruptive behavior disorders (DBDs), attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). The most common comorbid disorder in ADHD is ODD. DSM-IV describes three ADHD subtypes: predominantly inattentive type (ADHD-IA), predominantly hyperactive-impulsive type (ADHD-HI), and combined type (ADHD-C).
Predominantly hyperactive-impulsive
Most symptoms (six or more) are in the hyperactivity-impulsivity categories.
Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.
Predominantly inattentive
The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.
Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.
Combined hyperactive-impulsive and inattentive
Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.
Most children have the combined type of ADHD.
Treatments can relieve many of the disorder's symptoms, but there is no cure. With treatment, most people with ADHD can be successful in school and lead productive lives. Researchers are developing more effective treatments and interventions, and using new tools such as brain imaging, to better understand ADHD and to find more effective ways to treat and prevent it.
What are the symptoms of ADHD in children?
Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age.
Children who have symptoms of inattention may:
- Be easily distracted, miss details, forget things, and frequently switch from one activity to another
- Have difficulty focusing on one thing
- Become bored with a task after only a few minutes, unless they are doing something enjoyable
- Have difficulty focusing attention on organizing and completing a task or learning something new
- Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
- Not seem to listen when spoken to
- Daydream, become easily confused, and move slowly
- Have difficulty processing information as quickly and accurately as others
- Struggle to follow instructions.
Children who have symptoms of hyperactivity may:
- Fidget and squirm in their seats
- Talk nonstop
- Dash around, touching or playing with anything and everything in sight
- Have trouble sitting still during dinner, school, and story time
- Be constantly in motion
- Have difficulty doing quiet tasks or activities.
Children who have symptoms of impulsivity may:
- Be very impatient
- Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
- Have difficulty waiting for things they want or waiting their turns in games
- Often interrupt conversations or others' activities.
One of the most important thing to know about ADHD is that children with ADHD are at increased risk for developing other types of behavior disorders, including Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). The reason this is so important is that when this occurs, the long-term outcomes for children are likely to be much worse than for a child who has ADHD alone. The information below is intended to provide your with an overview of the diagnostic criteria for these conditions and how they differ from ADHD.
Oppositional Defiant Disorder (ODD)
Listed below are DSM-IV symptoms for ODD:- often loses temper;
- often argues with adults;
- often actively defies or refuses to comply with adult requests or rules;
- often deliberately annoys people;
- often blames others for mistakes or misbehavior;
- is often touchy or easily annoyed by others;
- is often angry and resentful;
- is often spiteful and vindictive;
For ODD to be an appropriate diagnosis, at least 4 of the symptoms listed above must be present for at least 6 months; the behavior must occur more frequently than is typical child of comparable age, and the behavior must create significant impairment in a child's social or academic functioning. In addition, the oppositional behavior can not occur only during times when a child is depressed.
An important difference that you will note from the symptoms of ADHD is that none of the ADHD symptoms involve behavior that is considered to be deliberate and willful. Although children with ADHD often engage in behavior that annoy others and fail to follow through on requests, such behavior is generally not deliberately and willfully initiated.
The kinds of difficulties that are associated with ODD are critically important to bring under control as soon as possible, because such behavior becomes more entrenched and difficult to change the longer it persists. In addition, children with ODD are at significant risk for the development of the more severe kinds of behavioral disturbance that is characteristic of Conduct Disorder, and the long term outcomes for children with Conduct Disorder are especially worrisome.
Conduct Disorder (CD)
Conduct Disorder (CD) is a more severe type of behavioral disorder than ODD that is also unfortunately more likely to develop in children with ADHD.
According to DSM-IV, the publication of the American Psychiatric Association that provides current diagnostic criteria for all recognized psychiatric disorders, the essential feature of CD is "...a repetitive and persistent pattern of behavior in which the basic rights of others or age appropriate social norms or rules are violated."
According to DSM-IV, the publication of the American Psychiatric Association that provides current diagnostic criteria for all recognized psychiatric disorders, the essential feature of CD is "...a repetitive and persistent pattern of behavior in which the basic rights of others or age appropriate social norms or rules are violated."
These behaviors fall into 4 main groupings:
1. Aggressive behavior that causes or threatens to cause harm;
*Examples: initiating fights; cruelty to people or animals;
2. Non-aggressive conduct that causes property loss or damage;
*Examples: fire setting with intent to cause damage; deliberate destruction of property;
3. Deceitfulness or theft;
*Examples: shoplifting; breaking into someone's house; frequent lying to obtain goods or avoid obligations;
4. Serious violation of rules;
*Examples: truancy from school; running away from home; staying out at night prior to age 13;
For the diagnosis of CD to be correctly assigned, at least 3 of the specific symptoms must have occurred during the prior 12 months, with at least one criterion present in the last 6 months. In addition, the disturbance in behavior must clearly result in clinically significantly impairment in the child or teen's social, academic, or occupational functioning. These criterion are intended to assure that the diagnosis is not assigned for an isolated antisocial act, but is instead reserved for youth who show a pattern of antisocial behavior over a significant period of time.
In addition to these core diagnostic criteria, individuals with CD often display a number of associated features as well. They often have little empathy or concern for the feelings and wishes of others; they are prone to often misperceive other's intentions towards them as being hostile which can lead them to overreact in a retaliatory, aggressive manner; guilt and remorse over clear misdeeds are often absent, other than feeling badly about having been caught; poor frustration tolerance and irritability are often present, and self esteem is often poor even though an image of "toughness" is often presented. CD is often also associated with the early onset of sexual behavior, substance use and abuse, excessive risk taking, and school suspension. Self-destructive behavior, including suicide, also occur at higher than expected rates. Not surprisingly, school suspensions, dropping out, and poor achievement are also quite common in individuals with CD.
NOTE: It is important to recognize that the explicit symptoms of CD do not really share any overlap with diagnostic criteria for ADHD. These two disorders certainly share many of the "associated features", but the actually symptoms that are used to make the diagnosis for each condition are really quite distinct.
This is why if a child with ADHD is also displaying the types of behaviors that may warrant a CD diagnosis, it is important not to attribute the antisocial behavior to just another facet of the child's ADHD. The danger in doing this is that the child may not receive the necessary and appropriate treatment as a result.
NOTE: It is important to recognize that the explicit symptoms of CD do not really share any overlap with diagnostic criteria for ADHD. These two disorders certainly share many of the "associated features", but the actually symptoms that are used to make the diagnosis for each condition are really quite distinct.
This is why if a child with ADHD is also displaying the types of behaviors that may warrant a CD diagnosis, it is important not to attribute the antisocial behavior to just another facet of the child's ADHD. The danger in doing this is that the child may not receive the necessary and appropriate treatment as a result.
Two different types of CD are currently recognized. The Childhood-Onset Type is defined by the onset of at least on symptom of CD prior to age 10. Thus, even though a child may not meet full diagnostic criteria before age 10, if these criteria are met when the child is 12, and at least one symptom was present (e.g. running away) before 10, the Childhood-Onset Type would apply. Almost all children who meet criteria for childhood-onset CD would have previously been diagnosed with Oppositional Defiant Disorder.
The second subtype of CD is called the Adolescent-Onset Type. This type is applicable to individuals who current meet the diagnosis for CD but who showed no symptoms of CD prior to age 10. Individuals with adolescent-onset CD are less likely to display aggressive behavior and are more likely to have decent peer relationships. Of utmost importance is that adolescent-onset CD less likely to be associated with serious behavior problems that persist into adulthood.
Although CD may occur in children as young as 5-6, it's onset is usually in late childhood or early adolescence. The course of CD is variable: in a majority of individuals, the disorder remits by adulthood. Nonetheless, a substantial percentage continue to display sufficient antisocial behaviors into adulthood to warrant the diagnosis of antisocial personality disorder as young adults. This is most likely to be true as noted above, for individuals whose CD begins early in life and is marked by aggressive behavior.
Data collected in numerous studies indicates that about 50% of children with ADHD will also develop ODD or CD at some point during their development. An interesting finding has been that although "pure" ADHD (that is, ADHD without either ODD or CD) is quite common in children, the reverse is less likely. In other words, it appears that most children under age 12 who meet criteria for ODD or CD will also be diagnosed with ADHD. In these cases, it appears that the impulsivity and over activity that is characteristic of ADHD children, and the ensuing difficulties this creates in parent- child, teacher-child, and peer relationships, increases the risk for the kind of conflictual interactions that promote the develop of these other disruptive behavior disorders.
THIS IS WHY IT IS SO IMPORTANT THAT PARENTS LEARN ABOUT THE KINDS OF SPECIALIZED BEHAVIOR MANAGEMENT STRATEGIES THAT ARE OFTEN HELPFUL AND NECESSARY FOR CHILDREN WITH ADHD.
Probably the most important thing a parent can do to help promote their child's long term success is to make sure that the proper steps are taken to prevent the development of these more severe behavior disorders that often develop in response to the problems that primary ADHD symptoms can cause.Here's why. The long term outcomes of children with pure ADHD and with ADHD and CD are very different. For example, in one study in which samples that followed two samples of ADHD children - one with high levels of aggressive behavior and the other without - there were no cases of drug or alcohol abuse at age 14 in the ADHD only group, while for the ADHD aggressive group, over 30% had engaged in substance abuse. In a similar study using different samples of children, approximately 1/3 of ADHD/CD boys had committed multiple crimes as teenagers compared to fewer than 4% of boys who had been diagnosed with ADHD alone.
