More American children than ever before are receiving treatment for “disruptive behavior disorders” including Attention Deficit, Bi-Polar, Conduct or Oppositional Defiant Disorders. Years ago, such children were just considered “discipline problems” for their parents and teachers.  Today’s approach is to recognize physical differences in brain chemistry and structure and to use medications and therapy. As an example, in the early 1980s, Attention Deficit Disorder (ADD) was almost unknown in this country with fewer than 300,000 children taking Ritalin.  Today over two million American children are taking Ritalin every day for ADD.

Each condition has its own treatment protocol with specialized drugs and therapies.  Yet most experts in the field admit that even they have a hard time distinguishing one behavior disorder from another.  Even when they consult the “Bible” of mental health diagnosis, The Diagnostic and Statistical Manual of Mental Disorder written through the American Psychiatric Association, they read about symptoms that overlap and mimic one another.

‘Psychiatry has made great strides in helping kids manage mental illness, but the system of diagnosis is still 200 to 300 years behind other branches of medicine,” according to Dr. Jane Costello, a leading expert on the subject at Duke University’s Department of Psychiatry & Behavioral Sciences.  She acknowledges that on the individual level, the experience can be a disaster for many parents and families. 

The same child can receive many different diagnoses, depending on who is the diagnostician.  Over the course of a few years, a child may even be diagnosed with various combinations of conditions such as Bi-Polar Disorder with Hyperactivity, Conduct Disorder with Anxiety, etc.  The reason is that these conditions not only do these conditions mimic one other, but also comorbidities or other problems often ”travel along” with the core disruptive behavior disorder.  For example, 60% of ADD children also exhibit such problems as learning disabilities, depression, moodiness, or tantrums.

It is important to diagnose each child correctly, especially from a pharmaceutical point of view. Children with ADD typically take stimulants like Ritalin. Yet Ritalin will only intensify the symptoms of bi-polar disorder. Nevertheless, “distinguishing between these two disorders can take years, according to William Stillman, the author of a guide for parents of bi-polar children.

In her recent study of juvenile bi-polar disease, Dr. Jennifer Harris reminds us “While we cannot deny drug treatment to children who are suffering, we must remember that such medications are not benign. Each has long- and short-term side effects.”  We must also make sure we give the right prescription to the each child.

Bi-Polar Disorder as a childhood illness is a very new and controversial concept in medicine.  Up until the mid-1990s, bi-polar disorder was classified as a chronic adult mental illness that usually appears around age 20.  Between 1995 and
2000, there were over 1.2 million new insurance claims for bi-polar children ages seven to twelve, and the rates are still going up, according to a study by Yale University.  Yet the jury is still out as to whether bi-polar disorder is the same as the adult version or if it will always become the adult version in later life. The reason is that there are no “universally-accepted diagnostic criteria” for children, as Dr. Harris writes. Even so, children as young as two years have been diagnosed with bi-polar disorder. 

In adults, the identifying symptom of bi-polar disorder is a manic phase that lasts about a week. During mania, the person may act giddy, talkative, distractible, and overly energetic.  Then the person may “crash” into a psychosis or deep depression. A child with extreme mood swings and mania that may last only a few hours may still be diagnosed as bi-polar.  

ADD children are distractible and impulsive.  The majority are also hyperactive.  They appear immature because they cannot control themselves or focus on tasks.  Like bi-polar children, they can exhibit “too much energy” and can’t concentrate in school. Unlike bi-polar children, their disorder is not often connected to suicide, anorexia, substance abuse, clinical depression, psychosis, and catatonic states. About half the children with ADD will outgrow the condition.

Oppositional Defiant Disorder (ODD) and Conduct Disorders (CD) are less about self-control and more about violating the rights of other people.  Children with ODDs are negative, defiant, touchy, angry, disobedient and hostile. They defy adults, blame others, and believe they are justified in what they do.  Children with CDs have little empathy toward others and are often violent and cruel. They may get into vandalism, truancy, physical fights, bullying, assault and even rape.

Children with any one of these behavioral disorders often appear temperamental and irritable. They may be failing in school and exhibiting problem behaviors for teachers. In many cases, a teacher will call parents for a conference, suggest that the child has ADD and would benefit from medication.  Parents then take the child

to their family doctor, who has little training in disruptive behavior disorders but will write out a prescription for ADD nevertheless.

Adults with mental illnesses can describe their symptoms to a psychiatrist, but children lack the verbal skills to do this.  Teachers and parents are the ones who describe behaviors to medical professionals.  Ideally, a team of professionals including a child psychiatrist, psychologist, child development specialist, speech pathologist and others should observe the child over the course of a few days in a controlled setting.  Blood tests and brain scans are part of a thorough diagnosis.  Yet this thorough process very rarely occurs because insurance companies will not pay for it and because there is a national shortage of child psychiatrists. 

Diagnosis is now art, not science.  Mistakes happen every day.  Recently, an eight-year-old girl who “spaced out” all day in school was put on Ritalin because her teacher thought she had a form of Attention Deficit Disorder.  It turned out that this child was a rape victim.  Children communicate through their behaviors, and often theirs is a hard language to understand and interpret.

REFERENCES

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. (Washington, DC: American Psychiatric Association), 2000.

Carey, Benedict. “What’s Wrong With My Child?” New York Times, November 11, 2006, pg. l.

Connelly, Elizabeth. Conduct Unbecoming: Hyperactivity, Attention Deficit and Disruptive Behavior Disorders. (Philadelphia: Chelsea House), 1999.

Dunne, Diane. “Statistics Confirm Rise in ADD and Medication Use,” Education World, posted at http://www.education-world.com/a_issues/issues148a.shtml