One out of five children has a mental health problem or disorder that is likely to disrupt his or her ability to perform age-related activities. These disorders include major depression, bipolar disorder, anxiety disorders, disruptive behavioral disorders, and schizophrenia (Box 13-1). In adolescence, the risk of mental health disorders increases significantly; eating disorders, aggressive and antisocial behaviors, and substance abuse are more prevalent than they are in younger children.²⁶ Effective treatment for mental health problems in childhood and adolescence is crucial, since mental health disorders and behavioral problems disrupt learning and social development, which, in turn, can have an effect on adult functioning. For example, disorders that develop in adolescence are associated with poorer occupational performance and adaptation in adulthood.²⁷

BOX 13-1 Quick Facts About Child and Adolescent Mental Health

• In the United States, 1 in 5 children has a diagnosable mental, emotional, or behavioral disorder (SAMHSA, 2009). However, 70% of children do not receive mental health services.

• Children and teens who have a chronic illness, endure abuse or neglect, or experience other trauma have an increased risk of depression (National Institute for Mental Health, 2000).

• Attention deficit hyperactivity disorder (ADHD) is one of the most common mental disorders in children. There are about two million children in the United States with this disorder (NIMH, 2009).

• It is estimated that 1 in every 33 children and 1 in 8 adolescents may have depression (Center for Mental Health Services, 1998). This is between 10% and 15% of all children and teenagers in the United States (SAMHSA, 2009).

• Depression is more common in teenage girls than in teenage boys (NIMH, 2001). Children with a parent who has depression are at an increased risk (SAMHSA, 2009).

• Approximately 750,000 children in the United States have bipolar disorder. If not treated, bipolar disorder puts children at an increased risk for drug abuse, school failure, and suicide (SAMHSA, 2010).

• Anxiety disorders are the most common mental, behavioral, and emotional conditions to affect children and adolescents This is Approximately 13 out of every 100 children aged 9 to 17 years in the United States has some form of anxiety disorder (SAMHSA, 2010).

• About 50% of children and teens with an anxiety disorder have a comorbid second anxiety or a mental or behavioral disorder, often depression (SAMHSA, 2010).

• Throughout the average lifespan, about 0.5% to 3.7% of females in the United States will develop anorexia and around 1.1% to 4.2% bulimia. Females are more at risk for developing an eating disorder than are males, but binge-eating disorders are more common in males (NIMH, 2010).

• Suicide is the third leading cause of death for 15 to 24 year olds and the sixth leading cause of death for 5 to 14 year olds in the United States (SAMHSA, 2010).

• Approximately 20% of the youths in juvenile justice facilities in the United States have a serious emotional disturbance, and most have a diagnosable mental disorder. An additional 30% of the youths in these facilities have substance abuse disorders or concurrent substance abuse disorders (OJJDP, 2000).

Data from the National Mental Health Association 2009-2010: www.nmha.org/infoctr/factsheets; National Institute for Mental Health: www.nimh.nih.gov/publicat/numvbers.cfm, or http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/; United States Department of Health and Human Services: Substance Abuse and Mental Health Services Administration 2007-2009: http://mentalhealth.samhsa.gov/, Surgeon General’s Report on Mental Health, 1999, Office of Juvenile Justice and Delinquency Prevention, [OJJDP] 2000.

Multidisciplinary pediatric services for children and adolescents with mental health and psychoemotional and behavioral problems are provided in a variety of settings, including psychiatric units in acute care hospitals, independent psychiatric hospitals, day treatment centers, and community mental health centers. Public schools provide psychiatric and mental health services as well. Many adolescents with mental health problems are also under the care of services such as the social welfare department or juvenile justice system and may live in a residential facility, group home, or foster care home.

In children and adolescents, mental health disorders often present as behavioral problems and/or as difficulty performing everyday activities. They are the result of the interaction of biological, behavioral, psychological, and social factors (Figure 13-1). Family history of mental illness, or sexual, physical, or emotional abuse or stresses associated with lower socioeconomic circumstances such as poverty or parental unemployment increase the risk of mental illness (Box 13-2). A biological predisposition or genetic component may make a child vulnerable to a mental health disorder, but a child will only develop a disorder when other factors are also present. Therefore, an integrative model that considers all biological, behavioral, psychological, and sociocultural dimensions is typically used to understand each child’s mental health disorder.³³

BOX 13-2 Warning Signs of Sexual Abuse

These signs do not mean conclusively that an adolescent or child is being sexually abused. They can also be symptoms of other problems or mental health disorders. However, if these symptoms are present, sexual abuse should be considered a possibility and an appropriate health professional consulted to discuss the reasons for these changes in a child or adolescents. All children are at risk of sexual abuse; for example, children with disability have a high risk of sexual abuse.

Warning signs of sexual abuse in children and adults are recent changes, including the following:

• Sleep problems without an explanation, e.g., nightmares

• Being distracted or distant

• A change in eating habits: refusing to eat, loss of or drastically increased appetite or trouble swallowing

• A sudden change in mood or fluctuating moods: rage, fear, insecurity, or becoming withdrawn

• A new interest in discussing sexual issues or making sexual comments or exhibiting adult-like sexual behaviors, language, or knowledge

• Disturbing sexual and nonsexual content in stories, art work, or dreams

• Developing new or unusual or excessive fears of people or places

• Becoming secretive or having secrets and refusing to discuss them with an adult or older child

• Having a new friend who is older or unexplained money or other gifts

• A change in attitude to body: self as bad or body as dirty, or similar

• Complaining of pain while urinating or defecating

• Symptoms of genital infections or discomfort

Signs common in adolescents involve the development of these behaviors or symptoms:

• Self-injury (cutting, burning)

• Decline in personal appearance and hygiene

• Using drugs and alcohol to excess

• Being sexually promiscuous

• Running away from home or withdrawing from activities

• Signs of anxiety or depression, including suicide attempts

• Fear of intimacy or closeness

• Eating disorders: binge eating, anorexia, or bulimia

These symptoms should never be ignored. It may be uncomfortable to initiate a conversation about them, but the best approach is always a calm, matter-of-fact one. An abuser threatens the child or adolescent; therefore, the children need to feel safe to disclose the secret and that you will cope with what they say without judgment and will listen. Since the abuser is often someone known to the family, the child may feel safe to talk to the OT practitioner, who is a person outside the family.

This material was compiled from suggestions listed on the following sites: http://www.stopitnow.com/warning_signs_child_behavior; http://www.protectkids.com/abuse/abusesigns.htm

FIGURE 13-1 Multidimensional factors of mental health. (Adapted from Sue D, Sue DW, Sue S: *Understanding abnormal behavior,* ed 9, Boston, 2010, Wadsworth Cengage Learning.)

The biological dimension includes genetics, and the structures and functions of the brain such as the role of neurotransmitters, sensory processing, and the endocrine system. Some disorders have explicit genetic causes that are present at birth. These conditions are often those with multiple symptoms, including intellectual disabilities. Other disorders have genetic or biological origins that are less clearly identified. This includes disorders such as depression, anxiety disorders, and those on the autism spectrum. The psychological dimensions encompass cognitive, emotional, and personality factors, namely, characteristics of personality, learning abilities, emotional arousal, coping abilities, self-concept, and self-esteem. The social dimension includes relationships of family, friends, and other significant adults (such as teachers and extended family), while the sociocultural dimension encompasses such factors as gender orientation (see Chapter 9), ethnicity, culture, religion, and socioeconomic status.

Disruptive behavior disorders

Disruptive behavior disorders are characterized by socially disruptive behavior that is often more distressing to others than to the individual. This category includes attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder.

Attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is the most common behavioral and cognitive disorder diagnosed in childhood in the United States.⁷ The three types are: (1) predominantly hyperactive-impulsive type, (2) predominantly inattentive type, and (3) combined type. A diagnosis of ADHD relies on an experienced multidisciplinary health care team to make the determination that the symptoms are interfering with the child’s ability to perform ADLs and that these symptoms are not the result of another medical, psychiatric, or social condition.¹⁹ It is necessary to rule out other reasons that children have difficulty paying attention in class, such as anxiety, sensory difficulties, feeling overwhelmed, fatigue, and boredom. Diet, routines at home, and exercise can also influence a child’s ability to pay attention in class. The symptoms must be evident before age 7, last for at least 6 months, and not be associated with an anxiety disorder.¹⁹

CASE Study

Thomas is a 7-year-old boy in a regular Grade 2 classroom. He has always had trouble in school. The kindergarten teacher describes him as “fidgety, restless, and distractible.” Now that he is in grade school, these symptoms are interfering with his learning. Thomas frequently stares off into space and has difficulty following multistep verbal directions. He is a shy, anxious boy. At home, his parents report that he needs frequent reminders to follow through with tasks. Thomas is easily frustrated and becomes bored with tasks quickly. For example, he does not brush his teeth adequately or get himself dressed in the morning. Instead, he gets distracted. His parents describe their frustrations with Thomas, his ability to lose things, forget assignments, and his untidiness.

After a comprehensive evaluation by a team of professionals (an occupational therapist, a physical therapist, a social worker, a psychologist, and a developmental pediatrician) and consultation with the teacher, the parents, and the child, Thomas received a diagnosis of attention deficit disorder (ADD), a form of ADHD. This type of ADHD affects both girls and boys equally. An evaluation includes a classroom visit, since one criterion for this diagnosis is difficulty in more than one situation (e.g., home and school). An OT practitioner (i.e., an occupational therapy assistant [OTA]) may observe Thomas at school or at home to establish a baseline of behaviors.

Interventions for ADD may include medication (stimulants), behavioral modification techniques, sensory modulation, and learning strategies to help these children focus on a task. Children with ADD generally respond to lower levels of medication compared with children with ADD of the hyperactivity type.¹⁴ Behavioral strategies can be very beneficial for these children. This may include classroom modification such as low sensory areas, which help children focus on their work and can be calming for a child when overstimulated (Table 13-1).

TABLE 13-1

Classroom Modifications to Improve Attention

SPECIFIC AREA	MODIFICATIONS
General strategies	• Use a child’s strengths. • Provide structure and clear expectations. • Use short sentences and simple vocabulary. • Provide supportive opportunities for success to help build self-esteem. • Be flexible in classroom procedures (e.g., allowing the use of recording device for taking notes and tests when students have trouble with written language). • Make use of self-correcting materials that provide immediate feedback without embarrassment. • Use computers for written work. • Reinforce social skills in school and at home. • Provide short breaks by allowing children to move, to stretch, or to verbalize in the classroom. • Mix up the responses required of students (e.g., Ask them to clap to the right response, sing the answer, or raise both arms). • Use positive behavior support techniques to reinforce learning.
Helping with schoolwork	• Show an interest in the child’s homework. • Ask about homework; ask questions that require answers longer than one or two words. • Help the child organize homework materials. • Establish a regular time with child to do homework; develop a schedule. • Find a specific place that has plenty of light and space and is quiet where the child can do homework. • Encourage the child to ask questions and look for answers. • Make sure the child justifies answers with facts and evidence. • Practice the skills taught in school and at home. • Relate homework to the child’s everyday life (e.g., teach fractions and measurements as you do other therapy activities, such as cooking). • Be a role model: Read a book or newspaper, write a letter with the child, or talk about your experiences of these activities. • Praise the child for both the small steps and big leaps in the right direction.
Language	• Have the child sit where he or she can hear you and not be distracted. • Repeat directions; remember to use gentle cuing and helpful reminders. • Provide visual cues for where to begin tasks and assignments. • NEVER embarrass students. • Phrase questions so that the student may answer “yes” or “no.” • Assign shorter written language assignments. • Provide written and verbal directions for homework (so that the child does not miss assignments).
Memory	• Use mnemonic strategies: Use rhyming games; allow children to mouth or whisper reading assignments in class. • Allow the children to underline in book or circle key words. • Use a recording device for taking notes. • Older children may enjoy using their ipod to keep track of their schedule and assignments. • Have the children practice memorization before bedtime. • Elaborate on information, and relate it to prior knowledge. • Allow the children extra time on tests and assignments. • Use visual or verbal learning. • Use active learning such as role-playing and hands-on experiences. • Divide information into categories for the child.
Sensory integration: coordination	• Allow the child to move around the classroom. • Ensure that the child goes to recess. • Provide the child with movement experiences. • Provide the child with quiet space when he is overly aroused. • Have the child sit in the back of the room, with few distractions. • Allow for breaks. • Provide noncompetitive games to help make all the children successful. • Work on the proximal control needed for handwriting skills. • Provide strengthening and endurance games. • Work on perceptual skills through gross motor activities (e.g., obstacle course).
Sequential processing	• Repeat instructions slowly and provide word or picture lists of steps. • Allow them to talk through or whisper the order of the steps during a task. • Anticipate difficulties. • Use a whole-word approach to reading.
Visual processing	• Provide graph paper or grid, which may help the child focus on the page. • Use tactile cues such as raised lines to help the child.
Organizational skills	• Establish routines. • Provide written as well as verbal instructions for assignments (e.g., a study guide for reading or task completion). • Outline the steps with the child so that he or she can learn the skill. • Develop strategies for taking notes (e.g., highlight key words or tasks). • Make lists, and check off the items (e.g., give the child a day planner; electronic day planners can be cool!). • Break long-term projects into small chunks.

Predominantly hyperactivity: impulsive type

Some children with ADD have excessive energy and motor activity. They are diagnosed with ADD of the predominantly hyperactivity type (referred to as ADHD), which is more common in boys and children from lower socioeconomic backgrounds.¹⁵ Signs of ADHD include fidgeting, squirming, talking excessively, and impulsive behavior (e.g., difficulty waiting one’s turn, and interrupting others who are talking). Other features associated with ADHD include sleep disorders, mood fluctuation, emotional hypersensitivity (i.e., emotional lability), poor self-esteem, and low frustration tolerance.²⁷ It is common for children with ADHD to experience difficulties relating to other children.

As in the case example of Thomas, a child with ADHD would receive a comprehensive evaluation before a diagnosis. The team of health care and educational personnel determines if there are any other causes for the impulsive-hyperactive behaviors. An OT practitioner observes and evaluates the child in the classroom, at home, and in the clinic and provides information on how the child’s behaviors affect his or her daily functioning, especially during play and learning tasks. The OT practitioner provides strategies and modifications to help the child regulate his or her emotional arousal and manage sensory distractions. Interventions include sensory integration therapy, accommodations and modifications in the classroom and home environment, self-regulation strategies, positive behavioral support, cognitive–behavioral therapy, and monitoring the behavioral outcomes of medication. OT practitioners work with teachers to develop therapy goals for an individualized education program (IEP). Their work with family involves developing parenting strategies to create an environment that supports a child to modify and regulate his or her behavior. The work with families and teachers is likely to involve positive behavior support strategies based on an applied functional behavioral analysis frame of reference (Table 13-2).¹²

TABLE 13-2

Psychosocial Frames of Reference

PSYCHOSOCIAL FRAMES OF REFERENCE	PRINCIPLES	STRATEGIES
COGNITIVE–BEHAVIORAL THERAPY
This frame of reference assumes that maladaptive or faulty thinking patterns adversely influence emotions and contribute to dysfunctional behavior. Examples of this faulty thinking include overgeneralizing (i.e., if it is true in one situation, it is always true) or catastrophizing (i.e., always thinking the worst possible outcome). The greatest improvement occurs when a child or adolescent decreases his or her negative and faulty thinking. This is not achieved by changing negative thoughts to positive ones.	How one thinks and what one believes influence behavior and emotions (e.g., a child’s positive or negative view of himself or herself and his or her view of the world as threatening or safe, caring, and supportive). A change in thinking can lead to improvement in function and can reduce emotional distress. The basic core and conditional beliefs are learned and become the personal rules that guide life (e.g., “if I do this (rule) the consequences are. . .”). It is a way of making sense of cause-and-effect relations. Focus on the present problems. Time-limited individual or group therapy focuses on a specific difficulty, condition, or skill acquisition.	Interventions include teaching a person about the relationships among their thinking, behavior, and emotions. Interventions: With the use of media and activities, the following techniques and skills are developed: • Identifying patterns of thinking and core beliefs and being aware of how thinking affects feelings and behavior (e.g., “I always fail”) and leads to anxiety in new situations and not trying new activities because of the fear of failure. • Cognitive restructuring, also called reframing thinking. This involves changing beliefs and thinking patterns. • Self-monitoring and self-talk • Learning skills to reduce stress, such as relaxation • Developing problem-solving skills to address client-identified problems • Homework assignments to consolidate learning and transfer it beyond the therapy setting
SKILL ACQUISITION
This frame of reference emphasizes that learning, practicing, and acquiring skills help children and adolescents function in social, academic, work, and family occupations.	Children develop self-efficacy, a sense of success, and skills through practice. Acquiring foundational skills can help children perform in home, school, and community settings. Skill acquisition is based on teaching-learning principles. Learning can be achieved through a therapist’s instruction or in an experiential group setting through peer modeling and observation. Skill refinement occurs through specific behavioral feedback. Skills are acquired sequentially (i.e., simple to complex).	Interventions are designed to develop, modify, and refine specific skills for functional occupational performance through instructional methods such as role playing, experiential skill–based groups, practice and generalization of skill performance, modeling, and feedback on skill performance.
BEHAVIOR MODIFICATION
This frame of reference changes or develops behaviors required for occupational performance. The OT practitioner identifies target behaviors and shapes these behaviors using reinforcement schedules. Applied behavioral analysis is a widely used frame of reference in health and education.	Children and adolescents exhibit behaviors that can be identified and reinforced. Changing or developing behaviors will improve occupational performance. Behavior can be modified by external forces (e.g., reward or punishment schedules).	Interventions are designed to develop, modify, and refine specific behaviors. Interventions follow strict protocols that are targeted to a specific behavior to be increased or decreased (e.g., increase eye contact from a child with autism or decrease head banging in such a child). Identify behaviors to be shaped, changed, or developed. Teach, demonstrate, and practice behavioral strategies. Increase desired behaviors with rewards (e.g., praise, tokens such as stars that can later be redeemed for a toy or an activity of one’s choice). Intermittent reinforcement strengthens a behavior.
PSYCHOEDUCATIONAL GROUP THERAPY
The purpose of the psychoeducational group is to share information along a common focus and learn from the experiences and knowledge of group members. This process facilitates change and/or the development of skills. This approach is often used in school-based programs to develop or improve social, communication, or coping skills.	Through knowledge comes change. To develop knowledge and skills for coping with crisis events, developmental transitions, mental health disorders, or current situational challenges (e.g., parental divorce, adolescent difficulties, depression, or bullying) Draws from cognitive–behavioral principles Education is a significant component. Focuses on the here and now Intentional use of group experience for mutual and vicarious (by the examples of others and observation) learning as well as support.	Time-limited and theme-focused groups of children and adolescents with similar needs or difficulties. A well-developed curriculum with sequential instructional sessions in which a variety of teaching methods are used, such as videos, handouts, PowerPoint presentations, and blackboards. Interactive and experiential learning strategies are important components. The techniques consist of brief lectures or presentations, small-group discussions, written exercises, role playing and behavior rehearsal, peer group modeling and learning from others, and homework tasks to reinforce learning and transfer it to everyday settings.
APPLIED BEHAVIORAL ANALYSIS
Positive Support Behavior: This approach consists of systemic and individualized strategies for achieving social and learning outcomes. The goal is preventing problem behavior.¹²	All behavior has a purpose for a child, and behavior is related to context. Challenging behaviors are symptoms. Interventions respect the child’s preferences, dignity, and goals. Relationships are the building blocks of prosocial behaviors Learning new skills takes time.	Teach skills directly. Ask why a child is acting the way he or she is acting, as there is always a reason. Identify patterns of behavior; if problems are predicted, they can be prevented. A-B-C Model: Identify the Antecedent behavior or event that precedes the child’s behavior. Identify the Behavior that is to be acquired or decreased, and establish Consequences and teach skills.
COACHING MODEL
The premise is that children will be more successful at reaching the goals that they develop themselves. Children will learn life-long strategies through setting goals and take progressive steps toward meeting goals successfully. This child-directed model requires that the OT practitioner provide direction, support, advice, and strategies. This takes the form of coaching and mentoring.	Children and adolescents will be more successful meeting goals that they develop. Children will develop life-long strategies as they learn to analyze the steps toward goals. Providing children with support and encouraging them will facilitate progress toward goals. Children may need “coach” support or mentorship to develop abilities to meet goals. Teach children to self-evaluate and problem-solve.	Children develop goals with support from OT practitioners. Analyze the steps to meet goals. Children set realistic tasks to meet goals. Support children in addressing steps and learning skills to meet goals. Get children to practice skills. Use cueing and reminders. Act as the children’s “coach” or “mentor” with weekly or daily “check-ins.”

CBT, cognitive behavioral therapy; OT, occupational therapy.

Data compiled from Furr SR: Structuring the group experience: A format for designing psycho-educational groups, J Specialists Group Work 25:29, 2000; Jones KD, Robinson EH: A model for choosing topics and experiences appropriate to group stage, J Specialists Group Work 25:356, 2000; Kramer P, Hinojosa J: Frames of reference for pediatric occupational therapy, ed 2, Baltimore, MD, 1999, Lippincott, Williams & Wilkins; Sommers-Flanagan R, Barrett-Hakanson T, Clake C, et al: A psycho-educational school-based coping and social skills group for depressed students, J Specialists Group Work 55:170, 2000; Stein F, Culter SK: Psychosocial occupational therapy: A holistic approach, ed 2, New York, 2002, Delmar; Crone D, Robert Horner R: Building positive behavior support systems in schools, New York, 2003, The Guildford Press.

The behaviors associated with ADHD, particularly the excessive motor activity and impulsivity, can frustrate parents, teachers, and other children in the family or classroom. Since these behavioral difficulties often are the presenting problem that precedes referral to the health care team, children with ADHD sometimes are regarded as “difficult,” “problematic,” or “stupid.” These negative labels can make these children feel inferior and create low self-esteem. They experience difficulties succeeding in school tasks and making friends, which also affect their self-esteem. As time goes on and even when others may have ceased to identify these children as problems, they may still identify themselves with the negative labels, which influences their behaviors and motivation for learning. They avoid trying because they have experienced failure. In this psychosocial dimension of therapy, the OT practitioner can help by explaining to parents and teachers how to work with the child to address his or her comprehensive needs in ways that will build confidence and self-esteem. Activities are graded (i.e., changed in some manner) so the level of difficulty is gradually increased to encourage success. Both parents and children can benefit from support groups, and the children can gain skills and confidence from participation in summer camps that focus on children with special needs.

CLINICAL Pearl

Teachers frequently mention to parents that their children have problems paying attention in class. This alone does not necessarily mean that the children have attention deficit disorder (ADD). The children may demonstrate attention problems for a variety of reasons. OT practitioners assist team members in determining if the attention problems are secondary to environmental, social, or sensory conditions. OT practitioners working in school systems play a role in educating teachers concerning the strategies and modifications that help these children succeed.

Conduct disorder: childhood onset

CASE Study

Rodney is a 10-year-old boy who has difficulty getting along with other children. His parents describe him as having been an irritable baby, a difficult toddler who had tantrums, and a young child who was disruptive in the family and did not adjust easily to preschool. Now, he is inclined to bully other children, and neighbors complain about his behavior (e.g., throwing rocks at windows, fighting with other children, and stealing). Particularly distressing is his cruelty to animals and, more recently, his fascination with fire. His parents feel powerless because he does not respond to their attempts to discipline him; of late, he has started hurting his younger sister. At school, he is doing poorly in Grade 3; he was suspended recently for stealing money from his teacher’s desk. The school has called a parent conference to discuss his aggressive behavior and poor school performance.

Rodney’s behaviors are characteristic of a conduct disorder, characterized by long-standing behaviors that violate the rights of others and the rules of society. The following behaviors characterize conduct disorder in children and adolescents:⁵^,¹¹

• Physical aggression toward other people or animals

• Participation in mugging, purse snatching, shoplifting, or burglary

• Destruction of other people’s property (e.g., setting fires)

• Breaking of rules (e.g., running away from home or skipping school)

• Impaired school performance, especially verbal and reading skills

• Suspensions from school for behavioral problems

Boys with conduct disorder are likely to be involved in behaviors such as vandalism, stealing, and fighting, whereas girls with the disorder tend to be sexually permissive (e.g., prostitution), and engage in manipulative behaviors such as lying or running away.

Other problems associated with conduct disorder are abuse of addictive substances, reckless behavior, and temper outbursts. Children diagnosed with conduct disorders also exhibit a lack concern for others, and they show no feelings of guilt or remorse. However, despite this image of toughness, they often have poor self-esteem and experience anxiety, depression, and suicidal thoughts.

Children with conduct disorder are at high risk of poor outcomes, including dropping out of school, unemployment, and engaging in criminal behaviors and substance abuse. If left untreated, many will develop antisocial personality disorder as adults (i.e., in approximately 40% of cases, childhood-onset conduct disorder develops into antisocial personality disorder).²⁹ Antisocial personality disorders are associated with serious crimes, including rape, physical assault, and homicide.⁵

CLINICAL Pearl

It is important to praise or recognize a child when he or she is working on or exhibiting desired behaviors. This recognition should be clear, and should label the behavior of the child, for example, “Well done, you are working quietly on the task.” This is better than saying, “Nice work!” This strategy helps the child feel validated and shapes his or her behavior.

Oppositional defiant disorder

CASE Study

Dwayne is a 9-year-old Grade 3 student. His mother states that he has always been a somewhat “difficult, angry” child, but his behavior has worsened over the last 19 months. He argues constantly with his parents and older sisters, loses his temper over seemingly trivial issues, and has uncontrollable rage. He blames others, refuses to obey his parents’ rules, and deliberately annoys other people. He says that he hates school and his sisters and that his classmates “suck.” His parents find it very difficult to set limits for him.

The primary symptoms of oppositional defiant disorder (ODD) are negative, hostile, and defiant behaviors that are uncharacteristic of typical children.⁵ Children and early adolescents with ODD display outbursts of temper, argue, defy adults, and are especially hostile to authority figures. These children seem to be angry all the time and resent rules; they become easily annoyed and readily blame others for their mistakes. Behaviors that might be observed are frequent temper tantrums; mean, hateful talking; revenge-seeking behaviors; and deliberately annoying others. These behaviors differ in duration and intensity from the occasional “difficult” periods some children and adolescents may experience.⁵ The ongoing oppositional behavior and stormy relationships with teachers and other children result in poor academic performance in school and few friendships.¹⁰ Children with ODD may eventually grow out of it, especially if the onset occurs in preschool years. Adolescents diagnosed with ODD are more likely (75%) to have symptoms that persist into adulthood.²

ODD may also be an indication of underlying childhood depression or an inability to cope effectively with anger and other uncomfortable feelings. ODD differs from conduct disorder in that these children do not seriously violate the rights of others or ignore their feelings. Furthermore, they rarely engage in activities that cause physical harm to others, and as a rule, they do not engage in criminal activity. However, an initial presentation of ODD may precede a diagnosis of conduct disorder.

Interventions involve working with family and teachers to develop a comprehensive program that is consistent across settings. It will involve limit setting with explicit consequences (e.g., time out) and positive behavioral support to encourage appropriate behaviors. Because of the benefit of experiencing personal control in some aspects of their lives, therapy can provide these children with choices and participation in goal setting. Strategies that develop self-regulation of mood and anger are effective in providing a child with a sense of control and can evolve into constructive expression of emotions that, in turn, will address underlying depression and anxieties.

CLINICAL Pearl

The OT practitioner working with children and early adolescents with disruptive behavior disorders must possess a thorough knowledge of developmental behavior patterns.