Defiance

Approximately one-quarter of children with ADHD experience significant difficulties in conforming to rules and regulations appropriate for their age, and these difficulties are usually seen both at home and at school. Parents of such children quickly learn that smacking and other forms of punishment are ineffective. Performance inconsistency, which is a prominent feature of ADHD, is often misinterpreted as implying that the child could succeed if only more effort were made. This chapter explores defiance in ADHD, including compliance as a function of the brain, the severity of defiant behaviour (oppositional disorder, conduct disorder), and the treatment of defiant behaviour.

Obesity and the Dual Diagnosis Child

Many children with excess weight and obesity struggle with comorbid psychiatric disorders and family stressors. These dual diagnosis presentations may be underestimated in epidemiologic surveys and frequently constitute exclusion criteria in childhood obesity treatment studies. As a result, clinical paradigms for this population are lacking and even multispecialty pediatric obesity centers do not provide comprehensive services to these children and their families. Hence, the need for this article, which is a preliminary exploration of possible dynamic mechanisms connecting several psychiatric diagnoses in childhood and excess weight. Based on correlations reported in the literature, depression, oppositional disorder, and attention-deficit/hyperactivity disorder are offered as examples of linear and reciprocal relationships between the two conditions. Notably, eating may be viewed as a means of regulating emotion (depression) and family conflict (oppositionalism) as well as reflecting a lack of regulation (attention-deficit/hyperactivity disorder). This article will hopefully generate subsequent research efforts in this area and enhance practitioner awareness of the complexity of providing effective services to this population.

Sex and Informant Effects on Diagnostic Comorbidity in an Adolescent Community Sample

Objective: To investigate sex and informant effects on comorbidity rates for anxiety disorders, depressive disorders, attention-deficit hyperactivity disorder (ADHD), and conduct–oppositional disorder (CD–ODD) in an adolescent community sample. Method: The Diagnostic Interview Schedule for Children-2.25 (DISC-2.25) was administered to 1201 adolescents and their mothers. Results: The highest comorbidity risk found was between ADHD and CD–ODD, with odds ratios (ORs) of 17.6 for adolescent reports and 12.0 for mother reports. The second-highest comorbidity risk, with ORs of 13.2 for adolescent reports and 11.0 for mother reports, was between anxiety and depressive disorders. There was not much overlap between internalizing and externalizing disorders. Adolescent girls had higher rates of coexisting anxiety and depressive disorders, whereas adolescent boys had higher rates of coexisting ADHD and CD–ODD. There was partial support for the hypothesis that adolescent-reported comorbidity rates would exceed mother-reported rates. Conclusions: There is a greater cooccurrence of within-category, compared with between-category, disorders. Adolescent girls are more likely to have coexisting internalizing disorders, while adolescent boys are more likely to have coexisting externalizing disorders. Mothers tend to report more externalizing disorders (that is, ADHD), while adolescents generally report more internalizing disorders.

Patterns of Critical Incidents and Their Effect on Outcome in an Adolescent Inpatient Service

Objectives: To identify patterns in critical incidents at an inpatient adolescent unit, to determine differences among patients who engage in critical incidents and those who do not, and to ascertain if there is an association between involvement in incidents and outcome of treatment. Method: Retrospective review of all critical incidents reported at an adolescent unit over 30 months. Results: Of 243 adolescents consecutively admitted, 100 (41%) were involved in critical incidents. Aggressive acts were more common in male adolescents, among patients with conduct or oppositional disorder and/or in those with specific learning disorders, and occurred throughout the day. Self-destructive events were more common in female adolescents and among patients with borderline personality disorder, and took place mainly in the evening. Adolescents involved in critical incidents tended to have longer admissions and had a worse outcome, irrespective of other factors. Conclusions: Critical incidents are common among hospitalized adolescents and result in a poorer outcome. Increased structure during the evenings, problem-solving and social skills programmes for patients, and specific training for staff regarding management and minimization of critical incidents should be provided.

Enrollment Predictors of the Special Education Outcome for Students with SED

Data pertaining to two outcome groups (75 successful completion and 76 unsuccessful) of elementary and secondary school students newly classified with serious emotional disturbance (SED) previously established by Mattison and Felix (1997) were analyzed. Enrollment variables (i.e., demographics, cognitive characteristics, family stressors, DSM-III psychiatric diagnoses, and multirater instrument ratings) were investigated for their ability to predict membership in the two outcome groups. Four baseline variables emerged as significant predictors of the unsuccessful outcome group: increasing enrollment age, any presence of a DSM-III conduct or oppositional disorder, WISC-R verbal IQ significantly lower than performance IQ, and absence of any DSM-III depressive or anxiety disorder. The overall concordance rate was 73.3%. A practical point system using the predictors was developed to estimate the probability of a successful or an unsuccessful outcome for a student newly identified with SED. Implications of the predictor variables are discussed in regard to comprehensive treatment planning for students newly classified with SED.

Boys' externalizing problems at elementary school age: Pathways from early behavior problems, maternal control, and family stress

Hard-to-manage preschool boys and comparison boys were studied at age 4 years and followed at ages 6 and 9 years. Externalizing problems at ages 4 and 9 were associated with concurrent family stress, but this relationship was partially mediated by negative maternal control. Cross-lagged regressions indicated that despite the high stability in children's problem ratings, observed negative maternal control at age 4 and self-reported negative discipline at age 9 predicted externalizing problems at age 9 years, controlling for earlier levels of symptoms. Hierarchical regression analyses revealed that problems were more likely to persist in the context of chronic family stress, defined as negative life events, marital dissatisfaction, and maternal depressive symptoms. When problem boys who met diagnostic criteria for Oppositional Disorder and/or Attention Deficit Disorder were compared with boys who were improved by age 9 years, family stress and earlier symptom levels, as well as maternal control differentiated between them. Teacher ratings suggested that these boys were on a clear pathway to persistent problems by age 6 years. A small sample of comparison boys with emerging problems also were living in more dysfunctional families and their mothers reported using more negative discipline at age 9 years.

Comorbidity between Disruptive Disorders and Depression in Referred Adolescents

Parent questionnaires from large Australian (N=2093) and American (N=500) clinic cohorts of adolescents were used to diagnose depression, attention deficit disorder with hyperactivity, and oppositional and conduct disorders. Co-occurrence of diagnoses was very high. Comorbidity between depression and conduct disorder was not higher than that expected for any psychiatric disorder (odds ratios =1.20 and 1.45 respectively for each cohort) while comorbidity between attention deficit disorder with hyperactivity and oppositional disorder was higher than expected (odds ratios =7.03 and 9.02) but comparable to that between conduct and oppositional disorder (odds ratios =7.35 and 6.14). Co-occurrence of depression with other disorders did not increase the likelihood of comorbid conduct disorder.