ODD/ADHD/Anxiety

Thanks, Mark. Our son is 16. He has ODD, comorbid with ADHD, anxiety, and dsygraphia. He is not abusing drugs, holds a part-time job and plays varsity soccer and JV tennis at his high school. His poor grades are 100% due to opposition to the system, complete lack of organization, difficulty paying attention, and lack of ambition. With his high intelligence, everything and everyone is "stupid" to him. He can out-think and out-smart most people he encounters and gets a thrill out of doing so. He would never tolerate tutoring or any kind of support from us, not even a "checklist" of things to turn in tomorrow. I'm looking for information about what is known about people with a profile such as his as they move into adulthood. Is there any literature or studies on this topic? What does your first-hand experience tell you? I just can't imagine him in a healthly, long-term relationship, but hope that I'm very wrong about that.

We have already looked into alternative schooling a bit, but in his mind, they all mean effort of one sort or another and, to him, effort is pointless. If he's going to do something he doesn't enjoy all day, he may as well be making money, so goes his argument. In any case, I don't plan on spending any time convincing him he should be in school in the fall. But, if he really means it, we'll make sure the rules for staying in our home are clearly spelled out.

In addition to my nagging worry about his long-term prospects, I would welcome suggestions you may have about how other parents move through the grieving process of not having the child they thought they had. And, finally, what is your recommended route for treating his anxiety? I believe that this plays a big part in his defiant behavior, because he is afraid of confronting a whole host of situations. Were he able to do so, his grades would be better, his self-esteem would be better, and we would be less frustrated with him on a regular basis. I'm just not sure how to go about getting treatment for that.... Doesn't that usually start with counseling.... Something we're avoiding at present because we're implementing your program.

Thanks, as always,

C.

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Hi C.,

Re: Is there any literature or studies on this topic?

Yes:

1. Bardone AM, Moffitt TE, et al: (1998) Adult Physical Health Outcomes of Adolescent Girls with Conduct Disorder, Depression, and Anxiety. J Am Acad Child Adolesc Psychiatry 37(6):594-601.
2. Bird Her, et all (1993), Pattterns of Diagnostic comorbidity in a community sample of children aged 9 through 16 years. J Am Acad Child Adolesc Psychiatry 32:361-368.
3. Buitelaar JK (2000) Open-Label treatment with Risperidone of 26 Psychiatrically-Hospitalized Children ad Adolescents with Mixed Diagnoses and Aggressive Behavior. Journal of Child and Aadolescent Psychopharmacology 10 (1) 19-26.
4. Carlson, Caryn et al: Gender differences in children with ADHD, ODD, and Co-occurring ADHD&ODD identified in a School Population. J Am Acad Child Adolesc Psychiatry , 1997, 36(12):1706-1714.
5. Griffiths MD (1998) Dependence on Computer Games by Adolescents - Psychol Rep; 82(2): 475-80
6. Kavousssi RJ, Coccaro EF (1998) Divalproex Sodium for Impulsive Aggressive Behavior in Patients With Personality Disorder J Clin Psychiatry 59:766-680.
7. Kuhne M, et. al Impact of Comorbid Oppositional or Conduct Problems on Attention-Deficit Hyperactivity Disorder (1997) J Am Acad Child Adolesc Psychiatry 36(12);1715-1725.
8. Rachel G. Klein, PhD; Howard Abikoff, PhD, et. Al. (1997) Clinical Efficacy of Methylphenidate in Conduct Disorder With and Without Attention Deficit Hyperactivity Disorder Arch Gen Psychiatry.;54:1073-1080
9. Riggs PD, Mikulich LM, et. Al. (1997) Fluoxetine in Drug-Dependent Delinquents with Major Depression: An Open trial. Journal of Child and Adolescent Psychopharmacology 7: summer 87-95.
10. Singer MI, Slovak K, et al: (1998) Viewing Preferences, Symptoms of Psychological trauma, and Vioent Behaviors Among Children Who Watch Television. J Am Acad Child Adolesc Psychiatry 37(10): 1041-1048.
11. Harrell JS; Gansky SA; et al: (1997) Leisure Time Activities of Elementary School Children. Nurs Res Sep-Oct; 46(5): 246-53
12. .Wiegman O (1998) -Video Game Playing and its Relations with Aggressive and Prosocial Behaviour. Br J Soc Psychol Sep; 37 ( Pt 3):367-78
13. Behrman: Nelson Textbook of Pediatrics, 17th ed., Copyright © 2004 Elsevier p 663.
14. Croonenberg J, Joerg M et al: Risperidone in Children With Disruptive Behavior Disorders and Subaverage Intelligence: A 1-Year, Open-Label Study of 504 Patients J. Am. Acad. Child Adolese. Psychiatry, 2005;44(1):64-72
15. Disney ER, Elkins IJ, et al: Effects of ADHD, Conduct Disorder, and Gender on Substance use and Abuse in Adolescence. Am J Psychiatry 1999, 156:1515-1521.
16. Findling RL, Kusumakar V, Daneman D, Moshang T, De Smedt G, Binder C (2003), Prolactin levels during long-term risperidone treatment in children and adolescents. J Clin Psychiatry 64:1362–1369.
17. Findling RL, McNamara NK, et al: A Double-Blind Pilot Study of Risperidone in the Tretment of Conduct Disorder. J. Am. Child Adolesc. Psychiatry 2000, 39(4):509-16.
18. Kasen S, Cohen P, et al: Influence of Child and Adolescent Psychiatric Disorders on Young Adult Personality Disorder. Am J Psychiatry 1999, 156: 1529-1535.
19. Kuperman S, Schlosser SS, et al: Relationship of Child Psychopathology to Parental Alcoholism and Antisocial Personality Disorder. J Am Acad Child Adolesc Psychiatry 1999, 38(6):686-692.
20. Lavigne JV, Cicchetti c , et al: Oppositional Defiant Disorder With Onset in Preschool Years: Longitudinal Stability and Pathways to Other Disorders. J. Am. Child Adolesc. Psychiatry 2001, 40(12):1393-1400.
21. Renauld J, Birmaher B, et al: Suicide in Adolescents With Disruptive Disorders. J. Am. Child Adolesc. Psychiatry 1999, 38(7):846-851.
22. SCHUR SB Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY). Part I: A Review J Am Acad Child Adolesc Psychiatry - 2003 Feb; 42(2); 132-144
23. Speltz ML, McClelllan J, et al: Preschool Boys with Oppositional Defiant Disorder: Clinical Presentation and Diagnostic Change. J. Am. Child Adolesc. Psychiatry 1999, 38(7):838-845.
24. Helgeland MI, Kjelsberg E, et al: Continuities Between Emotional and Disruptive Behavior Disorders in Adolescence and Personality Disorders in Adulthood. Am J Psychiatry 2005; 162: 1941-1947.
25. Johnson JG, First MB, et al: Adverse Outcomes Associated with Personality Disorder Not Otherwise Specified in a Community Sample. Am J Psychaitry 2005; 162:1926-1932.
26. Paris J: Personality Disorders over time: Precursors, Course and Outcome. Journal of Personality Disorders, 17(6), 479-488, 2003.
27. Reyes M: A randomized, double-blind, placebo-controlled study of risperidone maintenance treatment in children and adolescents with disruptive behavior disorders. Am J Psychiatry - 01-MAR-2006; 163(3): 402-10
28. Steiner H Divalproex sodium for the treatment of conduct disorder: a randomized controlled clinical trial. J Clin Psychiatry - 01-OCT-2003; 64(10): 1183-91
29. Wakschlag LS Is prenatal smoking associated with a developmental pattern of conduct problems in young boys? J Am Acad Child Adolesc Psychiatry - 01-APR-2006; 45(4): 461-7

Re: What does your first-hand experience tell you?

The long-term outcome for ADHD/ODD teens can be that they develop a Personality Disorder, which is one of the "labels" psychiatry uses to describe people who have traits in their personality that cause them major problems. These are not things that come and go but last for decades. A person's personality starts to form as a teenager, and that is when we see personality disorders start to form. We have all met people with these types of problems. They fit into a few big categories that have lots of different names.

One group is people who are strange, different, and keep to themselves. This is called cluster A. Another group is people who are dramatic, have lots of mood problems, are forever getting into trouble, and whose lives are quite mixed up. This is called cluster B. They are often very difficult to get along with over the long run. Another group are people who are withdrawn, scared, and have to do things a certain way. This is called cluster C. When any of these problems screw up people's relationships, ability to work, get them in trouble with the law, or make them miserable, we call it a personality disorder.

Recent studies have shown that children who have certain psychiatric problems are much more likely to get personality disorders as adults. Children who have multiple psychiatric problems are even more at risk. Children who have ODD are about four times more likely to have a personality disorder when they grow up, that is about a 15% chance. If they already have some signs of personality disorder as a young teenager, they are 25 times as likely to have a personality disorder as adults. What this tells us is that the longer these problems go on in childhood and as teenagers, the more likely they are to lead to personality disorders as adults.

There are two types of Personality Disorder in Cluster B, which are especially associated with ODD/CD. These are Borderline Personality Disorder and Antisocial Personality Disorder.

Borderline Personality Disorder is called this because patients have many traits from different psychiatric disorders. They have very unstable moods, like bipolar disorder. They often have strange experiences, like people with schizophrenia. Their relationships with others are usually quite unstable. They often don't have much of a sense of who they really are or where they are going. They often cut themselves. Most of the people with this problem are female. If you have ODD/CD and are female, you have approximately a 15% chance of getting this.

Antisocial Personality Disorder is basically a continuation of Conduct Disorder. People with this problem continue to not respect the rights of others or their property. They continue to get in fights or worse. They often are stealing or cheating. Usually they are involved with the law. They have extremely high rates of substance abuse and high rates of suicide and other unnatural causes of death. This is primarily a male diagnosis. Almost 20% of teenagers with ODD/CD with have Antisocial Personality Disorder as a result.

If you have a personality disorder as a teenager, by the time you are a young adult, here are the chances that these bad things will happen to you:

1. Difficulties with interpersonal Relationships 20-30%
2. Ending up with other Psychiatric problems 35-40%
3. Having at least one of the above bad outcomes 70-80%
4. Having at least two of the above bad outcomes 50%
5. Make a suicide attempt- 6-10%
6. Not get as far in school as you should have been able to 25%
7. Serious assault on another 25-35%

Some personality disorders are much more likely to improve over time. After 15-25 years, only about 10% of adults who had Borderline Personality Disorder continue to have it. That means 90% got over it. Antisocial Personality disorder tends to improve, too. However, about 25% of people with Antisocial Personality Disorder die prematurely. Of those that do not die, most are better, but few have recovered completely.

Re: I would welcome suggestions you may have about how other parents move through the grieving process of not having the child they thought they had.

This is covered in the eBook (Session #1 – online version).

Re: …what is your recommended route for treating his anxiety?

Parents can help their teen in these ways:

• Continue to provide structure, stability, and predictability. Within reason, stick to the same rules, boundaries, roles, and routines.
• Encourage your teen to participate in activities normally enjoyed. Support involvement in positive and pro-social activities (e.g., sports, volunteer work, church).
• Encourage your teen to talk about what he or she is going through, and be willing to listen. Don't just jump to conclusions and give advice. Depending on the situation, your teen may not want advice -- just to be understood. Even if a problem seems small to you, it may be a major concern for your child. Minimizing a problem or saying "you'll get over it" is not helpful. It gives the message you don't understand or are not willing to listen.
• Model effective stress management and coping skills.
• Offer reassurance, encouragement, and support. Be willing to provide verbal or physical comfort, but don't be discouraged if your teen rejects your effort or is irritable. These are normal reactions to stress. Be patient and let your child know you're available if he or she needs you.

Teens can decrease stress with the following behaviors and techniques:

• Avoid excess caffeine intake, which can increase feelings of anxiety and agitation.
• Build a network of friends who help you cope in a positive way.
• Decrease negative self-talk. Challenge negative thoughts about yourself with alternative neutral or positive thoughts. "My life will never get better" can be transformed into "I may feel hopeless now, but my life will probably get better if I work at it and get some help."
• Develop assertiveness training skills. For example, state feelings in polite, firm, and not overly aggressive or passive ways ("I feel angry when you yell at me" "Please stop yelling").
• Don't use illegal drugs, alcohol and tobacco.
• Exercise and eat regularly.
• Learn practical and effective coping skills. For example, break a large task into smaller, more attainable tasks.
• Learn relaxation exercises (abdominal breathing and muscle relaxation techniques).
• Learn to feel good about doing a competent job rather than demanding perfection from yourself and others.
• Rehearse and practice situations, which cause stress. One example is taking a speech class, if talking in front of a class makes you anxious.
• Take a break from stressful situations. Activities like listening to music, talking to a friend, drawing, writing, or spending time with a pet can reduce stress.

Mark