Disruptive Behavior Disorders in Children and Youth (Attention Deficit Hyperactivity Disorder, Conduct Disorder, Oppositional/Defiant Disorder, Disruptive Behavior Disorder NOS)
OPTIMAL OUTCOME OF TREATMENT
The child/youth attains a level of functioning in the areas of education, social situations, family relationships, peer relationships, leisure time, and/or legal involvement, as agreed upon by parents/guardian, youth, clinical team and involved others.
ASSESSMENT GUIDELINES (See Assessment Guidelines for Children/Youth.)
1. Children/youth should be assessed at intake for possible danger to self and others:
1.1 Assess for suicide potential since it is as high with these diagnoses as with depression.
1.2 Assess violence potential, including but not limited to: gang involvement, access to weapons, violence towards family members, substance use, etc.
2. Assessment should include the ability to: 1) empathize with others, 2) control impulses, and 3) feel guilt and remorse. Assessment should also address traumatic events such as prolonged separation, sickness, head injury, etc. The mental status exam should be age appropriate. Hallucinations are often missed in youth and should be included in the mental status evaluation. Comments of feeling extremely bored should cue further evaluation for depression.
3. Drug screens should be recommended when substance use is suspected, and when hallucinations are present. Standardized screening tools (such as the Adolescent Substance Abuse Subtle Screening Inventory-SASSI) may be helpful in identifying substance abuse.
4. Assess for co-morbidity with mood disorders, substance abuse, developmental disorders, learning disabilities, communication disorders, intellectual impairment, and psychosis. (Also consider that these illnesses may mimic disruptive disorders. Family history of mental illness may be helpful in this differential diagnosis.) The presence of one disruptive behavior disorder increases the likelihood of other disruptive behavior disorders being present.
5. Care must be taken to accurately distinguish oppositional defiant disorder from conduct disorder. The treatment prognosis is often very different.
6. Standardized behavioral assessments such as the Child Adolescent Functional Assessment Scales (CAFAS) and/or Achenbach Child Behavior Checklists (CBCL) for parents, teachers, school-age children or youth may be useful.
7. Assess the context and severity of the disruptive behavior and settings in which it occurs (home, school, community.) The context includes whether problem behaviors occur when alone or with peers, frequency of behaviors, intent to do harm, and whether actual damage occurred. These are also important prognostic indicators. For conduct disordered youth, prognosis worsens with early onset.
8. Assess the family, including discipline patterns and beliefs; age appropriateness of behavioral expectations for the child; substance abuse and attitudes of family members; marital discord and/or domestic violence; current and past maltreatment (including sexual/physical/emotional abuse and neglect); the child's role in the family. Children/youth with disruptive disorders are more likely to be/have been abused than the general population, and this requires careful evaluation. Also, families with domestic violence have a greater likelihood of children being abused.
TREATMENT GUIDELINES (See Treatment Guidelines for Children and Youth)
1. As these disorders are often manifest in uncooperative and angry behavior, intense negative reactions towards these children/youth are common. Clinical staff have the responsibility to be aware of and manage these reactions, and should seek supervision when appropriate.
2. Families should be informed of serious concerns regarding possible danger to self or others. Legal standards regarding duty to warn also apply.
3. Special skills are needed by families and others involved with children/youth with these conditions. Providing such skills to the family should be emphasized. Therapists may need to teach families how to independently access supportive community resources. All staff should avoid language that blames parents. Collaboratively developed behavior management plans are a critical element of treatment.
4. Family, group, social, and self-management skills development interventions are highly recommended treatment modalities. Individual therapy is generally not effective as the only treatment, especially for conduct disordered youth.
5. Medication may be effective in management of specific symptoms and symptom clusters, especially when other interventions have failed and the child/youth is at risk of placement in a more restrictive environment. Medications are usually effective in assisting ADHD children and youth with school, home, and peer functioning. Psychosocial interventions are generally also necessary.
6. Important elements of treatment include:
7. Wrap-around services such as respite, in-home, or in-school interventions and behavioral aide (trackers, youth proctors, mentors, etc.) are often very useful interventions.
8. Close coordination, including direct contact with the child/youth's teacher(s) is highly recommended. This coordination is important initially, and for ongoing evaluation of treatment progress. Advocacy for services to the child/youth may be needed.
THESE GUIDELINES
HAVE BEEN DEVELOPED BY:
THE UTAH PREFERRED PRACTICE CONSENSUS PANEL
UNDER THE AUSPICES OF THE UTAH
DIVISION OF MENTAL HEALTH
APPROVED MARCH 20, 1998