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As
discussed in several studies previously reviewed in ADHD RESEARCH UPDATE, the
development of significant behavioral problems in children with ADHD is often
associated with more negative long-term outcomes. For this reason,
understanding the factors associated with both the development and
persistence of important conduct problems in children with ADHD is extremely
important.
This issue was the focus of an interesting study published in a recent issue
of the Journal of the American
Academy of Child and
Adolescent Psychiatry (August, G.J., Realmuto, G.M., Joyce, T. & Hektner,
J.M. (1999). Persistence and desistance of Oppositional Defiant Disorder in a
community sample of children with ADHD. (JAACP, 38, 1262-1270). In this
study, the authors began with a sample of over 7000 children attending 22
different elementary schools in a suburban community, and using a combination
of behavioral screening procedures and diagnostic interviews, identified
those children who met diagnostic criteria for ADHD alone, ADHD and
Oppositional Defiant Disorder (ODD), and neither diagnosis.
As you may recall from a prior issue of ADHD RESEARCH UPDATE, the essential
feature of ODD is a persistent pattern of negativistic, defiant, disobedient,
and hostile behavior towards authority figures that persists for at least 6
months. Children with ODD often lose their temper, argue with adults,
actively defy and refuse to comply with rules and other demands, deliberately
annoy others, appear angry and resentful, act spiteful, and blame others for
their mistakes and misbehavior. Although all children may display such
behaviors from time to time, in children with ODD these behaviors occur much more
often and with greater intensity.
In this study, the authors were interested in learning several things. First,
they wanted to study what background factors differed between children with
ADHD alone, from those who were diagnosed with ADHD and ODD. Second, they
were interested in identifying factors predicted the persistence of ADHD and
ODD. Finally, they wondered how often ODD escalated into Conduct Disorder
(CD) and what factors were associated with this progression. As you may
recall, CD is an even more serious behavioral disturbance than ODD that often
involves criminal type behavior (for a more thorough discussion of ODD and CD
go to http://www.helpforadd.com/oddcd.html.
The sample of children identified to study included 79 with ADHD alone, 43 with
ADHD and ODD, and 111 children with neither diagnosis who were included as a
comparison group. Children were approximately 9 year olds at the start of the
study and were from primarily middle-class backgrounds. The ratio of boys to
girls in the sample was about 4:1. This study was conducted in Minnesota, and 95% of
the sample were white.
At the initial assessment, several measures were collected in addition to the
diagnostic interview data that was obtained for all participants. These
additional measures included basic demographic information on the families
(e.g. socioeconomic status, single parent status vs. intact family),
psychiatric information on parents (i.e. whether parents had a history of any
psychiatric diagnosis), and parenting practices. This latter factor was
designed to evaluate parents' use of different disciplinary practices and the
authors were especially interested in the use of what they considered to be
"negative practices" that involved inconsistent and punitive
approaches to managing children's behavior.
Four years after this initial assessment, a second diagnostic evaluation was
conducted, in which the authors were able to reevaluate approximately 60% of
the original sample. Although it would have been preferable if they were able
to retain a larger portion of the original sample, analyses they conducted
indicated that participants who dropped out did not differ significantly on
most characteristics from those who were reevaluated. Thus, it is reasonable
to assume that their findings are not unduly influenced by their having a
non-representative sample for the follow-up assessment.
Using this second round of diagnostic data, they were able to look at changes
in the symptom picture for each child, changes in the overall rate of
diagnosis, and to examine what types of background factors were associated
with these changes. The major questions addressed and the results of their
analyses are summarized below.
What was the stability of the initial diagnoses?
Of the 79 children who were diagnosed with ADHD alone at the initial
evaluation and reevaluated 4 years later, 36 - about 46% - continued to meet
diagnostic criteria for ADHD and no additional diagnosis. Another 21 - about
27% - continued to meet diagnostic criteria for ADHD and were also now
diagnosed with ODD as well. The same number - 21 - no longer met ADHD
diagnostic criteria and received no diagnosis at the follow up.
This is certainly encouraging in that it indicates that a significant number
of children with ADHD do experience a diminishing of symptoms over time to
the point where they no longer qualify for the diagnosis. It is important to
be aware, however, that even though a child/teen may no longer meet full
diagnostic criteria, he or she will often still be adversely affected by
residual symptoms of ADHD and continue to need extra help and support. Not
meeting full diagnostic criteria is definitely not always the same as not
having any difficulties related to ADHD symptoms.
Of the 43 children initially diagnosed with both ADHD and ODD, almost 50%
retained these original diagnoses. Fifteen still met diagnostic criteria for
ADHD, but their behavioral symptoms had improved to where they were no longer
diagnosed with ODD. Only 4 children from this group - about 10% - were not
given either diagnosis at follow up.
What factors predicted the emergence and persistence of ODD?
The authors first examined the factors associated with an ODD diagnosis at
the initial assessment. Specifically, their analyses considered whether child
IQ, socioeconomic status, history of psychiatric difficulty in the child's
family, gender, and negative parenting practices increased the likelihood of
the child being diagnosed with ODD.
The results indicated that only negative parenting practices was a
significant predictor that a child with ADHD would also be diagnosed with
ODD. To put this in perspective, they found that children whose parents
scored in the top 15% of the sample on a measure of negative parenting
practices were about twice as likely as other children to be diagnosed with
ODD. Children from families of lower socioeconomic status were somewhat more
likely to be diagnosed with ODD.
At the follow up evaluation, the strongest predictor of an ODD diagnosis was
whether or not the child had ODD at the initial assessment. Such children
were 8 times more likely than others to be diagnosed with ODD at the second
evaluation. In addition, however, negative parenting
practices was also an important predictor of whether or not the ODD diagnosis
would persist. Thus, children with ODD at time 1 whose parents were in the
top 15% for the negative parenting practices measure were almost twice as
likely as other to still have ODD 4 years later.
In addition, children diagnosed with ADHD initially also tended to be more
likely to be diagnosed with ODD 4 years later than the 111 comparison
children who had no diagnosis at time 1. Thus, this is an indication that the
presence of ADHD increases the likelihood that a child will develop important
behavior problems as well.
It is important to note that although these data indicate that parenting
practices are associated with the emergence and persistence of ODD, they do
not necessarily mean that negative parenting practices were the initial
"cause" of the child's ODD. Remember, all of these children were
also diagnosed with ADHD and children with ADHD present unique challenges to
parents in terms of behavior management issues.
Sometimes, the stresses that occur between parents and children in response
to a child's ADHD symptoms can precipitate a pattern of negative exchanges
that do contribute to the development of important behavior problems. Thus,
negative parenting practices can emerge in response to the frustration
associated with parenting a child with ADHD, which is certainly different
from arguing that such practices are the original cause of a child's
oppositional and defiant behavior.
It should also be noted that children with persistent ODD were more likely
than children whose ODD "desisted" to have extreme problems with
temper at the initial evaluation along with a tendency to be spiteful. Thus,
these particular symptoms appear to be especially common in children who are
likely to show persistent behavior problems.
What factors were associated with an initial diagnosis of ADHD or the
persistence of ADHD?
These results provide an interesting contrast to the results discussed above
for ODD. At the initial evaluation, none of the family background factors -
e.g. socioeconomic status, single parent vs. intact family etc. - was
associated with whether a child had ADHD, nor was the negative parenting
practices variable. Compared to parents of children without ADHD, however,
parents of children with ADHD were more likely to have ADHD themselves,
either currently or at an earlier time in their lives.
In addition, the only significant predictor of whether a child was diagnosed
with ADHD at follow-up was whether he or she was given the diagnosis
originally. Thus, parenting practices did not seem to be related to whether a
child was diagnosed with ADHD initially, or whether the child developed ADHD
over the subsequent 4 years.
IMPLICATIONS
I think there are several important implications that emerge from this study.
First, the fact that almost 75% of children diagnosed with ADHD initially
were still diagnosed with ADHD 4 years later indicates both that:
1. The disorder tends to be relatively stable over time, but
2. For a significant percentage of children, symptoms diminish over time to a
point that the diagnosis no longer applies.
At this point, it is still not possible to accurately predict which of these
possibilities will be true for a particular child. It is also important to
note that even among children who no longer meet full diagnostic criteria for
ADHD, in many instances they can continue to struggle with symptoms of the
condition. Thus, no longer meeting full diagnostic criteria is not the same
thing as a complete remission from the difficulty that ADHD can cause.
The reason I think this point is so important is because I have seen some
teens and their parents who were confused by the fact that they had been told
the teen no longer "had ADHD" and yet it was clear that the
adolescent was continuing to struggle in significant ways. Even when the full
diagnosis no longer applies, therefore, it can be critically important to
continue to provide the structure, assistance, and support that is often
needed.
The findings pertaining to the emergence and persistence of ODD are also quite
interesting. Recall that the primary predictor of ODD was the degree of
negative parenting practices that parents engaged in. These would include
such practices as overly harsh and punitive discipline, inconsistent
enforcement of limits and rules, overly restrictive rules, unrealistic
behavioral expectations, and failing to reward appropriate behavior.
As discussed above, these findings should not be interpreted as proving that
parenting is the fundamental cause of ODD. What these data do clearly suggest,
however, is that this is an area where parents have the potential to have a
substantial and important impact on their child's development. From this
study alone, we do not know what the long-term outcomes for children with
persistent ODD will be. Although few such children developed Conduct Disorder
- a more serious behavioral disturbance - during the course of the study, it
is certainly reasonable to speculate that the outcomes for those with
persistent ODD are likely to be more problematic.
The fact that such persistent behavior problems are associated with a higher
degree of negative parenting practices clearly implies that altering such
practices can play a critical role in promoting better behavioral adjustment
in one's child. Thus, getting professional assistance in learning the types
of child management strategies that can help to accomplish this can be an
enormously useful step for parents to take. I've got an introduction to
behavioral interventions at http://www.helpforadd.com/behtreat.html and would
also recommend a book called "Your Defiant Child" by Dr. Russell
Barkley. These resources can help get you started, but if this is a real
concern of yours, then consultation with an experienced child mental health
professional in your area would be highly recommended.
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