Behavioral disorders: accurate diagnosis proves challenging
Children placed in residential care present with a variety of behavioral disorders, sometimes with more than one. Determining a specific diagnosis can be daunting for the clinician.
Ashley Warhol, Psy.D is director of clinical services and internship training at Devereux Advanced Behavioral Health – MA & RI. She said that the two most common diagnoses she has seen at Devereux are attention deficit hyperactive disorder and oppositional defiant disorder, although others do exist.
“We are starting to see an increase in disruptive mood dysregulation disorder – or DMDD,” said Warhol. “Some DMDD is seen as the youth version of bipolar disorder, but not everyone agrees. We are seeing less pediatric bipolar and seeing DMDD instead.”
When it comes to ADHD and ODD, Warhol explained that distinguishing between the two is not that easy. “With ADHD and ODD, there is a high comorbidity. The prevalence on intake is relatively high. Our clinicians are charged with differentiating what’s going on with the student so they get a comprehensive case history of the patient during the first 90 days,” Warhol said. “We also administer a short self-report or observer report to differentiate between the symptomatology.”
Hallmarks of ADHD include inattention, inability to stay on task, disorganization and hyperactivity, acting without forethought, exhibiting impulsive behavior and desire for immediate rewards, Warhol noted. “We see ADHD across more than one setting. It’s related to an inability to complete non-preferred tasks and sustain attention.”
ODD, on the other hand, is seen less frequently, but presents as irritability and angry mood. Students diagnosed with ODD are often argumentative, defiant and their behavior is seen in only one setting. “It’s not just related to tasks, but is global persistent irritability,” Warhol said.
Some practitioners believe ODD falls under the ADHD umbrella. For instance, David B. Wolff, Ph.D., a neuropsychologist in Needham, Mass., questions the validity of an ODD diagnosis and suggests that it is “…simply bad behavior with no underlying brain symptoms,” he said. “It’s a label put on people to say they are behaving badly and don’t respond well to authority.”
However, Warhol said that past experience might increase the prevalence of ODD symptoms. “The difference is ODD increases in individuals who have experienced neglect or maltreatment or a hostile parenting environment. It’s an offshoot of trauma,” she said.
But she cautions clinicians to use care in diagnosing ODD, explaining that the presenting symptoms have to be “above and beyond age and cultural norms.” For example, all three-year-olds have tantrums. But if the intensity exceeds that of what a typical three-year-old might experience, there could be a problem, she said.
The same parameters apply to cultural factors. “If you work with a child who has been exposed to gang culture, their view of the world and how people interact is different from what others view. They don’t like to interact with authority figures. You have to take the behavior in context,” she said.
Ann Christie, Psy.D., certified school psychologist-doctoral level in Maine, has worked in the schools in Maine for the past 10 years and believes that ODD often does not meet criteria for special education services, “…certainly in Maine and I believe in other states as well.”
She said, “There is an exclusion for ‘socially maladjusted’ students as distinguished from those with ‘emotional disturbance.’ Often students diagnosed with ODD are seen to fall in the former category. As such, students who present with symptoms and characteristics, which may fit that diagnostic category, are either found to be ineligible for services and/or are identified using a different diagnosis, such as ADHD.”
Furthermore, Christie explained that school psychologists, at least in Maine, do not offer “treatment” for students. “They do the evaluations and social workers do the actual treatment in the school setting. It seems here that many programs for school psychology have only minimal coursework and training on counseling students, so psychologists who are asked to provide those services need to get further education to be able to do so,” she said.
In residential settings, behavioral therapy is used for both ADHD and ODD, although there are some specific interventions for each diagnosis, Warhol noted. “The cornerstone treatment for ADHD is medication. There are also school interventions to improve executive functioning. The school might devise a daily report card or develop a checklist and reward charts,” she said. Students with ODD typically do not receive medication, she added.
Zones of regulation are another oft-used therapy for ADHD, according to Warhol. “It helps students hone in on emotions and impulses. It’s a structured therapy curriculum done in group format and breaks emotions and experiences into zones. Students learn what emotions fall into what zone,” she said.
The color-coded zones provide tools that help the student understand how to cope with feelings and emotions. “They are specific to the student and what they are feeling. What works for one student might not work for another. They are individualized tools.”
For students with ODD, the focus is largely on parent training and management, explained Warhol. One specific therapy is Parent/Child Interaction Therapy, which promotes healthy connections between children and parents. She added that combination therapy, problem solving and family therapy provides a multi-system treatment plan that fosters more social skills. School-based programs and mentoring might also be part of the treatment plan.
“At the residential level we work to engage the family and do parent training with the goal of transitioning the child to home over time,” Warhol said. “In a residential setting, the reality is that a high percentage of students have experienced complex trauma, which convolutes the picture. PTSD and trauma can look like some other diagnosis.”
She further explained that diagnoses fall on a spectrum so it’s important to conduct a comprehensive case history that uses a biopsychosocial model.
“The reality is if you put six psychologists in a room and give them a case, you’ll get four to six different answers, based on academic training, field experience and the lens through which they see problem behavior. No one is necessarily right or wrong,” said Warhol.