Disorders With Typical Childhood Onset Esay
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Disorders With Typical Childhood Onset Esay
Introduction
You may have an idea of the population you most want to work with as a counselor. Perhaps you’re fascinated by adolescents, with their mix of cognitive complexity and emotional volatility. Perhaps you’d rather change professions all together than work with middle schoolers. Some of us are motivated to work with the elderly, a population which is rapidly growing across cultures and in need of experienced counselors to help navigate the changes and challenges of aging; others want to work with children.
In reality, none of us really knows where we will end up, or what population will be our specialized focus. This text is intended to prepare you for working with a wide range of clients, of varying ages, developmental stages, cultures, and presenting problems. In this chapter, we focus on several of the most common disorders occurring in childhood. But, before we begin, ask yourself what might be different when working with this specific population.
Mental health issues commonly diagnosed in childhood or adolescence are divided into two main categories: childhood onset disorders and learning disorders. These disorders are usually first diagnosed in infancy, childhood, or adolescence, and are described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013) in several different sections. Here we focus on the disorders that counselors will see and treat most often. This is by no means a suggestion about which issues are more severe; as in other sections of this book, we focused our attention on the presenting problems most likely encountered in counseling settings. These include autism spectrum disorder and attention deficit/hyperactivity disorder, which are found in the Neurodevelopmental Disorders chapter, as well as Oppositional Defiant Disorder and Conduct Disorder, which are found in the Disruptive, Impulse-Control, and Conduct Disorders chapter of the DSM-5.
Autism Spectrum Disorder (ASD)
Autism Spectrum Disorder, generally referred to as Autism, encompasses a group of complex and varying neurodevelopmental disorders which can severely impact a child’s ability to understand and interact with others and their environment. The use of the term “spectrum” speaks to the wide range of severity and symptoms included under this umbrella term. Prior to the DSM-5, autistic disorder, childhood disintegrative disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS), and Asperger’s Syndrome were all distinct diagnostic categories with specified criteria.
The revisions in the DSM-5 reflect current research that identifies social/communication deficits and repetitive/restrictive behaviors as the core features of ASD. Researchers believe that the new diagnostic criteria will result in fewer children being misdiagnosed with autism (Ozonoff, 2012). The DSM-5 also added a new diagnosis of Social (pragmatic) Communication Disorder (SCD). Some clients who do not qualify for an ASD diagnosis may qualify for SCD, which is defined as an impairment of pragmatics. Individuals with SCD have difficulty with the appropriate social use of verbal and nonverbal communication in real-life contexts. For example, there may be impaired ability to change communication styles to match a changed context, difficulty making inferences, or following the rules of conversation. Social relationships and ability to understand social conversation are adversely impacted. A diagnosis of ASD must be ruled out before the diagnosis of SCD is applied.
The new category of ASD in DSM-5 is intended to include DSM-IV diagnoses of Autism, Asperger’s Syndrome, and Pervasive Developmental Disorder-Not Otherwise Specified. Although Asperger’s syndrome is no longer in the DSM as a diagnosis, some may continue to use the term to refer to those on the mild end of autism spectrum disorder. There is some concern among practitioners that discontinuing the separate diagnosis of Asperger’s Syndrome will impact the ability of those individuals at the high functioning end of the spectrum to have access to appropriate services. Other changes in the DSM-5 include the removal of language delay as a criterion for ASD.
In addition, there is a more inclusive age-of-onset criterion so that while symptoms must be present since early childhood, it is recognized that they may not fully manifest until later in life when social demands exceed the capacity of the individual to cope (Lai, Lombardo, Chakabarti, & Baron-Cohen, 2013). Rather than requiring a diagnosis in early childhood, DSM-5 facilitates adult diagnosis by acknowledging that some symptoms may not become apparent until adolescence or adulthood, when social demands increase. There must be symptoms in the early developmental period, but these may not be evident until later when situational demands overtax coping skills. Developmental history, delays, and regression are also taken into account by the DSM-5 criteria.
ASD is characterized by deficits in communication skills and reciprocal communication, repetitive patterns of behavior, and neurological and developmental delays. Although every diagnosis of ASD presents somewhat differently, children suffering from this disorder typically show little interest in making or retaining friendships or initiating social interaction, and can become engrossed with a single object or idea to the exclusion of whatever is going on around them. ASD can also be associated with intellectual disabilities, motor coordination issues, and other health issues (i.e., sleep and gastrointestinal disturbances). On the other hand, some with ASD can excel in such areas as visual skills, music, math, or art.
The number of cases of ASD has increased drastically over the past few decades, with the most current studies reporting that approximately one child in every 88 could potentially fit the diagnosis (Volkmar, Paul, Rogers, & Pelphrey, 2014). More conservative estimates are that prevalence is approaching 1% of the population, both children and adults (American Psychiatric Association, 2013), which makes ASD one of the most common developmental disabilities. It is unclear if the recent rise in reported cases is due to increased awareness, lower thresholds for diagnosis, or a true increase in prevalence. The disorder usually appears quite early, between 12 and 24 months of age (APA, 2013). Depending on the severity, ASD can be a devastating diagnosis for a child and family.
DSM-5 groups the diagnostic criteria for ASD in two general categories: persistent deficits in communication and interaction across multiple contexts, and restrictive and repetitive patterns of behavior.
Deficits in social communication and interaction must not be accounted for by general developmental delays, and are manifested by problems with social-emotional reciprocity; for example, difficulty having a normal back and forth conversation, or in developing or maintaining friendships. This may look like a reduced sharing of interests or emotions, or a failure to initiate social interaction at all. The individual also must have deficits in nonverbal communication, such as abnormal eye contact, facial expressions, or body language. There is also a distinctly abnormal approach to social interaction and difficulty developing and maintaining relationships. The child may display little or no affect, have difficulty engaging in pretend play, or display little interest in interpersonal communication. Unfortunately, these shortfalls result in difficulty making friends, understanding verbal and nonverbal cues, and adjusting behaviors to fit various social situations.
The second diagnostic criteria centers on restrictive, repetitive patterns, interests, behaviors, or activities. Typical behaviors might include repetitive speech, use of objects, or motor movements. Examples include such things as lining up toys by size or repeating a teacher’s instructions numerous times. The child may be highly restrictive, rigid, and inflexible, and very resistant to change. Children may insist on having the same thing for lunch every day, or having a specific bathroom or bedtime ritual. Some children may be interested in studying only one subject, or one topic. In addition, individuals with ASD may be either hypersensitive or hyposensitive to sensory input. For example, children may seem indifferent to pain, or have a severe reaction to loud noises or vibrant colors. Alternatively, children may show an unusually strong interest in sensory aspects of their environment that can result in excessive smelling or touching of certain objects or a fascination with objects that are lit or spin.
In the DSM-5, severity and specifiers are also important concepts to keep in mind when considering an ASD diagnosis. The severity scale is designed to be more descriptive of the impact that ASD has on everyday functioning, and refers to the level of care or support the individual is likely to need. Practitioners are hopeful that the severity scale will help substantiate the need for workplace accommodations and a more supportive workplace environment for individuals diagnosed with ASD.
There are three severity levels: requiring support, requiring substantial support, and requiring very substantial support. An example of level one severity may be a child who is able to communicate in complete sentences, but has trouble engaging in peer communication and back and forth conversation, and has trouble engaging socially with peers. The child may also have rituals and repetitive behaviors that are difficult to interrupt.
Level two is typified by marked deficits in both verbal and nonverbal social communication skills. The child may speak only in simple sentences, have limited and stunted social interaction, and exhibit marked repetitive behaviors that are noticeable to casual observers and interfere with functioning.
Level three is marked by severe communication deficits in verbal and nonverbal communication. The child rarely initiates interaction with peers, and needs substantial help with day-to-day activities. There is marked distress if there is any interference with repetitive behaviors and rituals. Specifiers include: with or without accompanying intellectual impairment; with or without accompanying language impairment; and associated with a known medical or genetic condition or environmental factor.
Social Communication Disorder, in contrast, involves impairment of pragmatics and low communication abilities and social participation, but not the restricted, repetitive patterns of behavior and interests that would result in an ASD diagnosis.
Comorbidity
ASD frequently co-occurs with intellectual impairment and language difficulties. A majority of those with ASD will also have another mental health diagnosis (van Steensel, Bögels, & de Bruin, 2013; Volkmar, Paul, Rogers, & Pelphrey, 2014). Specific learning disabilities, eating and sleeping issues, and developmental coordination disorder are common co-occurring disorders (APA, 2013).
There are some overlapping symptoms with ADHD, such as hyperactivity, inattention, and distractibility. A diagnosis of ADHD would be made if those symptoms are above and beyond what you would expect to see with ASD and for that developmental stage. An individual can be diagnosed with both, but only if he or she meets the criteria for both disorders.
Cultural Considerations and Population Factors
Although there may be differences in communication styles and early childhood developmental expectations from culture to culture, those with ASD would be considered out of the norm in any context. The DSM-5 takes into account varying norms for social interaction, and requires that the individual’s behavior and communication patterns be out of the norm for that social cultural group. Recognition and diagnosis may be delayed for specific populations, especially those of lower socioeconomic status and those with limited access to adequate health care. This is an important consideration, since early intervention is thought to be a key to treatment.
ASD is four to five times more likely in boys than girls. Again, there is no specific causal link for this discrepancy, although some experts believe that this is due in part to underdiagnosis in females (Volkmar, Paul, Rogers, Pelphrey, 2014). DSM-5 uses identical diagnostic criteria for ASD for males and females, but some researchers believe that gender-specific criteria would be more accurate, and might shed light on potential underdiagnosis of females. Some researchers speculate that the higher incidence in males may be related to fetal testosterone levels and sex differences in brain structure (Baron-Cohen et al., 2011)
An alternative explanation that has been proposed for the male bias is that females, especially those with milder symptoms, may be misdiagnosed with other conditions that also involve the exercise of excessive attempts to control the environment or others, such as Borderline Personality Disorder or Anorexia. Females could also be underdiagnosed if they are more motivated to learn to conform socially (Baron-Cohen et al., 2011).
Etiology and Risk Factors
Although ASD has no identified cause, there are many theories regarding what risk factors are associated with the diagnosis, including low birth rate or premature birth, advanced age of parents, and fetal exposure to carcinogens. Although once popular in mainstream media, the belief that the use of vaccines has a link to ASD has been disproven by many research and meta-analysis studies (Volkmar, Paul, Rogers, & Pelphrey, 2014). Given the wide variance in symptoms and severity, there is most likely a complex etiology that includes genetics, brain development, and environmental factors. Studies are focusing on issues, such as viral infections, complications during pregnancy, and pollutants to see if any of these are contributing factors.
Some children may have a genetic vulnerability that environmental variables can compound. There appear to be several different genes associated with ASD, which may influence brain chemistry and development, throwing off the brain’s delicate balance and ability to develop normally. These genes may be inherited or disrupted by trauma or other factors. Many studies have found autistic syndromes, symptoms, or traits in the close relatives of children diagnosed with ASD, including individuals whose personality traits are similar to autistic symptoms (Pickles et al., 2000). A recent study reported that for the 85% of cases of ASD where specific multigenic influences could not be identified, it was found that in approximately one quarter of families affected by autism, multiple family members had either clinical or subclinical autistic traits (Constantino, Zhang, Frazier, Abbachhi, & Law, 2010; Virkud, Todd, Abbacchi, Zhang, & Constantino, 2009).
Treatment Interventions
Research shows that early intervention is key. This usually involves several educational, compensatory (helping the child use areas of strength to address areas of need), and behavioral interventions (Handleman & Harris, 2000; National Research Council, 2001). These services typically include help with communication, gross and fine motor skills, and social interaction. Children diagnosed with or at high risk for developing ASD may be eligible for services through the Individuals with Disabilities Education Act (IDEA), so it is important to coordinate intervention efforts with other professionals and to help the family look for resources within their community.
Treatment most often focuses on symptom reduction and supporting developmental and communication skills (Sicile-Kira, 2014). Educational interventions concentrate on improving academic and cognitive skills and are intended to be administered in school-based settings. Allied health interventions include therapies typically provided by speech and language, occupational, and physical therapists, and may include auditory and sensory integration, music therapy, and language therapies.
Behavioral interventions focus on minimizing behaviors that interfere with daily functions, such as self-injury or repetitive movements. Counselors are more likely to be involved in teaching children how to act in social situations, developing social skills, and helping the family develop structured environments and coping strategies. Most of these interventions use principles of applied behavioral analysis (ABA), but may vary in specific methods or environmental setting. One example of a studied ABA intervention is Pivotal Response Treatment (PRT). PRT is a play-based intervention that concentrates on “pivotal” areas of childhood development, including self-management, emotional regulation, motivation, and behavioral cues in social interaction. PRT highlights naturally occurring reinforcement and motivational strategies. The belief is that by targeting these important developmental hurdles, the effects of PRT would generalize to other environmental settings (Koegel & Koegel, 2005, 2012). PRT strategies are a core component of an early intervention approach called the Early Start Denver Model, which we discuss below.
The UCLA/Lovaas and the Early Start Denver Model (ESDM) are specific manualized sets of interventions that have gained some popularity and have research supporting their effectiveness (Rogers & Dawson, 2009a,b,c; Rogers, Dawson, & Vismara, 2012). Specific interventions emphasize social skills and include such interventions as social stories, imitation, joint attention training, peer training, and play therapy.
Interventions tend to be intense, comprehensive, and involve many different helping professionals. Some may be delivered in specialized programs or centers, while others are home, agency, or school-based.
Attention Deficit/Hyperactivity Disorder (ADHD)
Most children will have times when they fidget, have trouble paying attention, or just can’t seem to sit still and focus on a task. For children suffering from ADHD, these behaviors can seem constant and out of control. Inattentiveness and hyperactivity interfere with their day-to-day functioning and can have a severe impact on the child’s ability to function and thrive in a school environment.
As part of the diagnostic criteria, ADHD begins in childhood. The disorder is most often diagnosed during the early years of schooling, but in some cases is not diagnosed until adolescence or adulthood even though, in retrospect, symptoms began much earlier. It is important to note that research shows that between 30 and 70% of children with ADHD continue to have symptoms of the disorder when they become adults (Kessler et al., 2006). Counselors may have adult clients who have been struggling with ADHD for much of their lives, and may not have received any treatment until adulthood; often the lifelong struggle has a negative effect on self-esteem as individuals may be repeatedly told that they are “stupid” or “lazy.”
ADHD is usually diagnosed before the age of 12 and surveys suggest it affects roughly 5% of children (APA, 2013). Many parents or caregivers first observe the hyperactivity, although it may be hard to distinguish this from normative behaviors of children at a young age. The DSM-5 diagnostic criteria are split into two main areas: the first criterion is marked by persistent patterns of inattentiveness, and the second focuses on hyperactivity and impulsivity.
Inattentiveness and distractibility can manifest in many ways. The child may often make careless mistakes, or may have difficulty readily organizing or accomplishing even simple tasks. Children may have trouble following directions and may not seem to be listening, even when they are spoken to directly. They are often forgetful, lack the ability to follow through on things, such as daily chores and homework, and lose or misplace things easily. All of these issues can combine to make the child reluctant to engage in school fully, especially when asked to perform complicated or time-consuming tasks (which become more prevalent as the child moves up in grades).
The other set of criteria focuses on impulsive behaviors and hyperactivity. Children may often fidget or seem unable to control their bodily movement, sometimes finding things to drum on or making other repetitive movements that may be loud and distracting to other students in the classroom. They tend to interrupt the teacher or other students, and have great difficulty waiting for their turn. They may leave their seat or place in line for no apparent reason, or climb or run in situations where that behavior is not appropriate. Many children with ADHD talk inappropriately in class, again because they are unable to control their impulsivity. Teachers or parents may describe them as “always on the go,” “high energy,” or “out of control.”
The Case of Gabby
Gabby is an 8-year-old third grader who is struggling at school. Although she seemed to do fine in school until now, third grade is turning out to be a struggle for her. She misplaces her homework or forgets to complete it at home. She frequently fails to complete her tasks fully or read all of her reading assignments. Gabby’s teacher has noticed her inability to focus, difficulty with working in a group, and lack of attention to details. Although she can sometimes work on her own and in small time frames, Gabby gets easily distracted when working with peers; she tends to ramble when she talks and often will go off on tangents when asked a question.
Gabby’s teacher reached out to her parents to express her concern over Gabby’s behaviors and lack of attention. Her parents first noticed there was an issue in first grade. She seemed disorganized and wasn’t able to tell them her homework assignments. They felt as if they had to repeat instructions to her and many times she did not seem to be listening. She never seemed to finish reading any of her books, always moving on to something else before she even got halfway through. Gabby has two older brothers and one younger sister. One of the older brothers has a diagnosis of ADHD.
Gabby says that she likes school and tries very hard, but just can’t seem to follow directions or “get it.” She likes more active classes, such as gym, art, and music, but struggles with math and English. She has several close friends and loves to talk and play games. She loves dance and is on a traveling soccer team.
Comorbidity
Roughly 60% of children diagnosed with ADHD fit the criteria for another mental health disorder (Pliszka, 2011). The most common comorbid diagnoses are mood disorders, such as anxiety and depression, conduct disorder, and language and communication disorders. It is important to note that differential diagnosis is key with ADHD, as its symptoms can present as similar to certain anxiety and mood disorders, such as Generalized Anxiety Disorder (GAD) or Bipolar disorder. Prior to the DSM-5, the diagnosis of ADHD was not made for individuals diagnosed with a disorder on the autistic spectrum. DSM-5 now allows for both disorders to be diagnosed if criteria for both are met.
Cultural Considerations and Population Factors
A greater percentage of children from higher socioeconomic levels appear to receive a diagnosis of ADHD. Research found that parents of minority children were less likely to seek treatment and felt that there were substantial issues that prevented their children from being properly diagnosed or receiving effective treatment (Livingston, 1999; Taylor & Leitman, 2003). These barriers included fear of labeling, lack of knowledge regarding mental health issues, fear of misdiagnosis, and language issues (Hervey-Jumper, Douyo, Falcone, & Franco, 2008).
There are also many theories as to why there is a significant discrepancy in diagnosis levels with regard to gender. Girls with ADHD frequently do not exhibit the observable behavior problems that boys do, such as violent outbursts or aggressive behaviors. Instead, girls often exhibit symptoms associated with inattentiveness, and busy teachers may easily miss these more subtle cues (Hinshaw, 2002).
Etiology and Risk Factors
As with all of the disorders in this chapter, the specific causes of ADHD are not fully known. However, it is clear that there is a strong genetic component and that ADHD appears to be highly heritable; studies show that parents with ADHD have a greater than 50% chance of having a child with the same diagnosis (APA, 2013). Studies also show that children and adults with ADHD tend to have abnormal levels of certain neurotransmitters like dopamine as well as irregular nerve pathways that regulate behavior (APA, 2013). Neurotransmitter levels have been linked to issues, such as attention, learning, movement, sleep, and mood. In many cases, however, there is no hereditary linkage.
There also appear to be common environmental factors that contribute to the likelihood of an ADHD diagnosis. These include smoking, taking drugs, or drinking during pregnancy, premature birth or low birth weight, and birth or early brain injury related medical issues. Additionally, there is some evidence that environmental toxins, such as lead or PCBs, may also be linked to higher risk of developing ADHD.
Treatment Interventions
Counseling interventions employed for ADHD typically include behavioral, cognitive behavioral, family-based, and relaxation techniques (National Institute of Health, 2008). Most research suggests that medications like stimulants are most effective in treating the primary symptoms of ADHD. Although behavioral techniques when used alone seem to have limited impact on symptomology, they can decrease disruptive behaviors and improve social skills and parent-child relationships (Brown et al., 2005). Those interventions that include multiple approaches, such as medication, family, school-based, and behavioral techniques appear to have a greater impact than any one intervention alone (Brown et al., 2005). It is important to note that CBT interventions are more often used with adult populations, and appear to be less effective with younger populations (Roman, 2010).
Behavioral Therapy
Behaviorally based treatments focus on training parents, teachers, or other caregivers to implement contingency management programs and reinforcement schedules. Parents generally attend parent training programs where they are given assigned readings and instruction in standard behavioral techniques. Some research shows behavioral interventions to be effective in the treatment of ADHD (Fabiano et al., 2009; Daley et al., 2014). Interventions typically include creating everyday routines, organizational interventions, and behavioral reinforcement. Environmental interventions can include limiting choices, reducing distractions, chunking of assignments, and changing parent and teacher interactional strategies. Typical behavioral interventions revolve around goals and reinforcements, as well as discipline when necessary.
Counselors and school counselors often work with teachers in a consultation model to teach behavioral strategies for application in the classroom. The use of a daily report card system where the child receives tokens or points for certain target behaviors in the classroom is a popular example of a behavioral program for children with ADHD.
Cognitive-Behavioral Interventions
CBT interventions focus on emotional regulation, self-talk and self-instruction, self-monitoring, and problem-solving strategies. As with CBT interventions discussed in previous chapters, the goal of these interventions revolves around teaching self-control, decatastrophizing, and self-reinforcement. Counselors typically try to accomplish these goals through modeling, role playing, and practicing cognitive strategies (cognitive restructuring, thought stopping and thought replacement, scaling, and contingency management) (Szigethy, Weisz, & Findling, 2012). For example, a child may be taught to stop a thought of “I am out of control and everyone is looking at me” and replace it with a more effective emotion-regulating thought like “I can get back on track and I only missed a little of what the teacher said.”
The premise is that individuals with ADHD tend to lack internal cues that keep then on task or the ability to take in cues from the environment. It is important to note that cognitive behavioral interventions were prevalent in the 1980s and 1990s for ADHD, but the use of CBT with younger populations has waned in the absence of strong research to support its efficacy.
Medication
For those individuals with ADHD, stimulant medications such as Adderall or Ritalin are the best known and most widely used treatments (Greenhill & Ford, 2002). Typically, these stimulant medications are paired with behavioral or cognitive behavioral interventions. Contrary to popular belief, it is important to note that not all children with this diagnosis are given a prescription for stimulants; however, between 70% to 80% of children with ADHD respond positively to these medications, which may help with concentration. But, there is mixed evidence of significant long-term effects on school achievement or behavioral management (Prasad et al., 2013).
Oppositional Defiant Disorder (ODD)
Every child can have a bad day, a day where they totally lose control or throw a tantrum in a supermarket because their mom would not buy them their favorite sugary cereal. For some, however, an irritable mood and frequent outbursts are more the rule than the exception. Oppositional defiant disorder (ODD) is characterized by irritability and negativity in almost every setting and evidenced by frequent outbursts and verbal tirades. Often, these outbursts are directed at those individuals in authority, such as teachers, caregivers, and parents. At other times, behaviors may be purposeful attempts to annoy peers. Children with ODD are easily offended and described by peers as jealous, vengeful, blaming, unstable, and difficult to be around (Essau, 2014).
It is clear from the above list of symptoms that these children can cause significant distress to family, friends, and school systems. Consequently, children with ODD have difficulty making friends or functioning successfully in a school system, resulting in significant distress for the child as well.
ODD is a comparatively common childhood disorder with prevalence estimated in the National Comorbidity Survey Replication at between 6% to 10% (APA, 2013; Nock, Kazdin, Hiripi, & Kessler, 2007). ODD is diagnosed more often in boys than in girls, and diagnosed more often in younger children, perhaps to avoid mislabeling what is thought to be normative teenage behavior (Essau, 2014).
To fit the DSM-5 diagnosis for ODD, the child must regularly exhibit four of the following behaviors: arguing with adults, losing temper, actively defying or refusing to comply with rules or requests from authority figures, intentionally behaving in a way that annoys another person, being angry or resentful, being easily annoyed by others, being vengeful or spiteful, and blaming others for their own misbehavior or mistakes. Negativity and defiance are often expressed through obstinacy, resistance to direction, and unwillingness to share or compromise. Examples of defiance may also include constant testing of limits and boundaries, arguing, ignoring, and failing to accept blame or consequences.
The aggression may manifest itself in verbal or physical hostility, though this is usually without the more severe aggression and physicality seen in Conduct Disorder, which is described in the next section. These behaviors need to last at least six months to fit the diagnosis and symptoms must cause significant impairment in social, academic, and occupational functioning. Keep in mind that in almost all cases, the child does not see themselves as out of control or in the wrong, but views their behaviors as appropriate in response to the unreasonable demands that the authority figures put on them.
The Case of Drew
Drew, a 7-year-old first grader, has been sent to the school counselor and principal on numerous occasions. The most recent incident involved an incident of elopement. Drew walked away from the playground and refused to come in after recess was over. After the incident, while in the school counselor’s office, Drew refused to talk or even acknowledge that the counselor was present. Drew’s teachers have expressed high levels of frustration and feel as though the interventions they have tried so far have had little impact. Drew refuses to be placed in “time-out,” and when disciplined makes comments like “I don’t care if I can’t eat lunch with my friends, I don’t like them anyway.” His teachers believe that his outbursts and disruptive behaviors are negatively impacting the other children’s ability to learn.
Drew argues almost constantly with peers, and is obsessed with catching other students who are not following the rules. He talks almost nonstop while in school, and in less structured environments, such as the bus or recess, his talking increases. He repeatedly ignores the rules his teachers set and the directions they give in class. He does not accept responsibility for anything, and often accuses other students of doing the same thing that earned him a reprimand from the teacher.
Drew’s parents were divorced when he was four, and he now lives with his mother and two older brothers. Drew’s mom describes him as “out of control” with “no respect for me or his father.” When she tries to punish or reprimand him at home, Drew says he does not care about losing TV or computer privileges. His mother says that he is always going into his older brothers’ rooms and taking things from them without asking. He hardly ever comes when called and sometimes “runs away” for hours at a time to other houses in the neighbourhood or to the neighborhood playground. He also tries to play one parent against the other with comments like “Dad lets me stay up till nine when I’m at his house, that’s why I like him more.”
When Drew finally opens up to his school counselor, he quickly becomes loud and overemotional. He says that no one understands him and he does not care about school or getting good grades. He describes his older brothers as bullies and his mother as overbearing and domineering. He says that none of the trouble he gets into at school is his fault, and no one likes him. When asked if there is anything he would like to do differently or change, he replies “Why should I change, it’s not my fault!”
Comorbidity
Studies suggest that roughly 15 to 20% of those diagnosed with ODD also fit the criteria for ADHD. Anxiety (14%) and depressive disorders (9%) are also highly correlated with ODD (Angold, Costello, & Erkanli, 1999). Most children with Conduct Disorder (CD) begin with ODD-like behaviors. Studies indicate that the majority of children with ODD do not develop CD, but ODD is usually present as a forerunner to childhood-onset CD (APA, 2013).
Cultural Considerations and Population Factors
Although present at all economic levels, ODD appears to be overrepresented in lower socioeconomic groups (Loeber, Burke, Lahey, Winters, & Zera, 2000). This may be due to limited access to medical and psychiatric services in younger years, as well as an increased exposure to the risk factors examined below.
In addition, research suggests that children from minority populations who have anxiety or depressive disorders may be misdiagnosed with ODD or CD instead, in part because of stereotypes and biased attributions for behavior. For example, children with affective and anxiety disorders may also exhibit irritability and may refuse to take part in situations perceived as dangerous; as a result, this may be misinterpreted as oppositional behavior (Lau et al., 2004).
Etiology and Risk Factors
Like most of the disorders discussed in this chapter, research has not found any specific environmental trigger or underlying cause of ODD. Most experts believe that there are many contributing environmental and biological risk factors, including the child’s temperament, developmental delays in cognition or communication, lack of or inconsistent parental support and supervision, previous abuse or neglect, and possible brain chemical imbalances. Environmental stressors affecting a child’s sense of consistency and security may also play a role in increasing disruptive behaviors. Examples include parental divorce, financial issues, frequent moves or school changes, and child care changes.
ODD may be best understood in the context of a biopsychosocial model, which considers biological risk factors and harmful aspects of the child’s environment. Some experts believe that children with ODD seem to lack the cognitive or emotional skills required for executive functions (i.e., problem solving, working memory, task completion) to comply with the requests from authority figures. These deficits undercut the child’s capacity to regulate emotion; thus, the child loses his or her temper as well as the ability to cope or problem solve (McKinney & Renk, 2007).
Treatment Interventions
Counseling treatment usually involves behavioral, cognitive behavioral, or family approaches. Individual counseling interventions usually focus on emotional regulation, healthy expression of feelings, and cognitive restructuring, which helps the child to look at events more realistically.
Behavioral-based intervention emphasizes extinguishing inappropriate behaviors and learning more appropriate and adaptive behaviors. Caregivers and parents are taught reinforcement techniques, and when appropriate, punishment techniques. The hope is that appropriate behaviors eventually become habitual and naturally reinforced by the child’s everyday environment.
Family-based interventions focus on parent training, communication, family roles, and behavioral interventions. Parents are taught to implement behavioral contracts, as well as methods for extinguishing unwanted behaviors and reinforcing positive ones. Counselors stress to caregivers the need to be consistent in the use of secondary gain (appropriate rewards) and the importance of the child eventually getting primary gains (naturally occurring rewards from the environment). Again, the hope is that these new appropriate behaviors become more habitual as they get reinforced. For example, if a child is able to stay on task longer in class they may answer a teacher’s question correctly. The teacher then gives verbal praise which increases the likelihood of that appropriate behavior continuing.
One specific family intervention, parent-child interaction therapy (PCIT) focuses on parent-child interaction patterns and on improving the parent-child relationship. PCIT is divided into two stages: parent-child relationship development and discipline training. The goals of the first stage are to develop a loving and nurturing parent-child bond through interactive play. The goals of the second stage mainly focus on skill development and behavioral reinforcement. Sessions consist of the therapist coaching parents in behavioral techniques, usually with the help of a one-way mirror and a headset audio device (Bodiford McNeil, Hembree-Kigin, & Anhalt, 2011).
Although medications are not normally used in the treatment of ODD, children with co-occurring disorders, such as ADHD or Generalized Anxiety Disorder (GAD), may be taking some form of medication.
Conduct Disorder (CD)
Any counseling professional will tell you that it is not uncommon for adolescents to test boundaries, break rules, and get in trouble. However, there are some children and adolescents who show consistent patterns of violating others’ rights and displaying behaviors that fly in the face of established social norms and the law. Conduct disorder is exemplified by prolonged periods of antisocial behaviors, the breaking of established rules and social norms, and violations of the law. Most often, professionals view conduct disorder as similar, but much more serious than ODD and a possible precursor to antisocial personality disorder (Murphy, Cowan, & Sederer, 2001).
Because of the behaviors associated with this diagnosis, individuals with CD are frequently viewed by peers, adults, and agencies as delinquent, “bad,” or “the criminal type.” Symptoms vary depending on the severity of the disorder and the age of the child, but fall into four distinct behavioral clusters: destructive, deceitful, aggressive, and violating established rules. Examples of destructive behaviors include arson and vandalism. Aggressive behaviors include bullying, cruelty to animals, physical altercations, and forcing sexual activity. Deceitful behaviors involve lying, cheating, shoplifting, and other criminal activity. Rule breaking examples include skipping school, running away, or engaging in activities not suitable for that age group.
Children with CD have more difficulty in terms of academic struggles, interpersonal relationships, and drug and alcohol use. The legal system is more often involved as well, putting youth at risk for a downward spiral if intervention does not happen (Boesky, 2002).
The lifetime prevalence of CD is estimated to be around 10%. Similar to ODD, more males than females receive the diagnosis (12.0% among males and 7.1% among females). Based on specific research, it is interesting to note, however, that there is a great deal of variance in the presence of specific behavioral criteria from 33% reporting repeatedly staying out at night without parental permission to 0.3% reporting that they forced some kind of sexual activity (Nock, Kazdin, Hiripi, & Kessler, 2006).
The Case of Ryan
Ryan is a 15-year-old sophomore in high school who has had many “run-ins with the law.” The most recent incident involved stealing his mother’s credit cards and going on a shopping spree with his friends. His mother called the police and Ryan spent six months in a juvenile detention center and currently has a parole officer. His presenting problems in counseling include issues with probationary restrictions, violent outbursts, alcohol and other drug use/abuse, and feelings of overall anxiety and depression.
As a child, Ryan moved from town to town and school to school. Ryan has four siblings and two stepsiblings. His parents divorced when he was six, and he lives with his mother and three of his siblings. Ryan states that his father is an “angry drunk” and used to hit him when he was younger. His mother was also an alcoholic and drug addict, but seems to be abstaining at this point. Ryan’s mom has also been diagnosed with Bipolar Disorder and is taking medication. He was very close to his paternal grandfather, who was killed in a car accident when Ryan was twelve.
Ryan has been suspended from school several times and removed from his most recent school for bullying, marijuana possession, and several fights with fellow classmates. His school record indicates that he has a history of skipping school, failing classes, and having altercations with teachers. He has been arrested on several occasions, once for arson, and twice for disorderly conduct.
Ryan’s mom reports that he continually lies about where he is going or what he is doing. After this most recent incident, she no longer wants Ryan living with her and his other siblings. She says that Ryan “has always gotten into things he shouldn’t have way earlier then he should have.” He started smoking and drinking at a very early age. Mom remembers the first time he got in trouble with the law was when he was ten and stole candy and playing cards from the local grocery store.
Comorbidity
Those diagnosed with CD are at a significantly higher risk of meeting the criteria for at least one other disorder, especially substance abuse and impulse control disorders (APA, 2013). Some research suggests that the correlation with ADHD may be as high as 50% (Nock, Kazdin, Hiripi, & Kessler, 2006). Approximately 30 to 40% of those persons diagnosed with CD will have a co-occurring mood disorder. Most will have academic issues and co-occurring learning disabilities. Because at least 60% will have an additional mental health or learning disability, it is important to have a multidisciplinary approach to treatment, including incorporating medical, educational, community, and mental health services (Essau, 2014).
Cultural Considerations and Population Factors
CD is more commonly diagnosed in neighborhoods characterized by social disorganization and high crime rates (Loeber et. al., 2000). The symptoms of the disorder revolve around breaking rules, violating others’ rights, and violating social norms. This leaves open the question of who decides which norms and rules are appropriate, how to judge when these norms and rules have been broken, as well as the impact that the environment and poverty play.
As with ODD, children from minority cultures who have anxiety or depressive disorders may be misdiagnosed with CD if their behavior is misattributed to oppositional reasons (Lau et al., 2004).
Etiology and Risk Factors
Conduct disorder involves an interaction of genetic/biological, environmental, and social influences; there is no single cause of CD. Research suggests genetic and biological influences, since behavioral disorders tend to cluster in families. Some research found that individuals with CD may inherit a lower baseline autonomic nervous system, and may need greater levels of stimulation to feel normal or “alive.” This genetic predisposition may account for the higher level of sensation seeking activity associated with this disorder (Davidge et al., 2004; Lahey, Hart, Pliszka, Applegate, & McBurnett, 1993). Children with CD have a low resting heart rate (Mawson, 2009); this underarousal may result in sensation seeking and engaging in disruptive behaviors in order to get to an optimal arousal state, or it may reduce a sense of guilt or anxiety that inhibits such behaviors in other children (van Goozen, Snoek, Matthys, Rossum, & Engeland, 2004).
Environmental factors include parental mental health issues and substance abuse, chaotic family situations, and childhood abuse and neglect (APA, 2013). Another risk factor appears to be inconsistent parenting styles where the child does not learn the relationship between behaviors and consequences, or is reinforced for tantrums and noncompliance by overwhelmed or uninformed parents. Early childhood temperament patterns, such as irritability and inconsolability, are risk factors as well. Finally, social risk factors include lack of structure, community violence, lack of parental supervision, and dysfunctional family environments.
Treatment Interventions
Treatment of children with conduct disorder is complex and challenging; depending on the severity of the behaviors, treatment can be provided in a variety of different settings. Adding to the challenge of treatment are the child’s uncooperative attitude, and sometimes fear and distrust on the part of the adults. In developing a comprehensive treatment plan, a child and adolescent psychiatrist may use information from the child, family, teachers, community (including the legal system), and other medical specialties to understand the causes of the disorder.
As we’ve emphasized throughout this book, every client and every situation is different. Individualized treatment plans should be developed to address the particular problems and severity of each child and family situation.
Counseling Interventions
Behavior interventions and counseling are frequently employed to assist the child in appropriately expressing and controlling anger and aggression. Parents are often trained in behavioral management and educational programs as well as ways to cope with the chaos that this disorder can bring to the family structure. Because of the high comorbidity rates, interventions may also include medication as well as typical treatments for the co-occurring disorders. Because of the severity of the symptoms involved, the course of treatment is seldom brief and may include a multidisciplinary approach.
Eyberg, Nelson, and Boggs (2008) identified sixteen evidence-based treatments for disruptive behavior disorders that all include a focus on increasing reinforcement of more prosocial and compliant behaviors, utilizing appropriate punishment for disruptive behaviors, and training parents to be consistent and predictable in their application of reinforcement and punishment. Other factors which impacted the success of these interventions were the parents’ willingness to make changes to their own behavior, such as discontinuing substance abuse.
Family-Based Interventions
One popular approach is Parent Management Training (PMT) (Feldman & Kazdin, 1995; Kazdin, 2005). In this highly researched and evidence-based approach, parents are trained in ways to assist their children in problem solving, emotional regulation, and impulse control. PMT interventions focus on maladaptive parent-child interactions mainly involving discipline practices, and rely heavily on principles of operant conditioning. The counselor starts by providing an overview of underlying concepts and instructional sessions that involve social learning principles and behavioral techniques, modeling behaviors for parents, and coaching in implementation of specific conditioning techniques.
Multisystemic Therapy (Henggeler & Lee, 2003) is another evidence-based, integrative, family-based treatment designed to improve psychosocial functioning for children and their families.
Behavioral Family Therapy is another evidence-based approach that has been used for many years with children diagnosed with ODD and CD (Eyberg, Nelson, & Boggs, 2008). Techniques in Behavioral Family Therapy include shaping, reinforcement, behavioral contingencies, and behavioral contracts. The counseling process involves several steps, including establishing rapport, identifying problematic behaviors, developing goals, choosing rewards/punishments, and finally creating the behavioral contracts. In behavioral family therapy, the family environment, the child’s temperament, unproductive behaviors, and negative reinforcement are all addressed in an attempt to modify the family system as well.
Other Treatment Approaches
Group assertiveness training has also been used effectively in school-based groups for middle schoolers (Huey & Rank, 1984).
When CD is severe and persistent, or when the family is unable or unwilling to commit to treatment, children may need an alternative placement to keep either the child or the family safe. As always, the least restrictive setting should be used for the briefest time possible. Therapeutic foster care or respite care may also be an option.
Studies show that multifocused psychosocial interventions that are delivered early in development to at-risk children show the most effectiveness. The importance of prevention and early intervention cannot be overstated (Connor et al., 2006).
The use of medication for CD and ODD has not been well studied, and current research suggests that medication should be used only when evidence-based psychosocial treatments have not worked, and that medication should not be the sole treatment for these disorders (Connor, 2002: Connor et al., 2006). On the other hand, medication may help treat comorbid disorders so that the child can benefit from the psychosocial interventions for CD/ODD.
Case Conceptualization Considerations Using the T/C Model
The disorders described in this chapter are diverse in terms of etiology and treatment. Keep in mind that environmental stressors may play a substantial role in the development of disruptive behavior disorders, such as parental conflict, divorce, poverty, and unsafe neighborhoods. Additionally, deficits in problem solving, emotion regulation, and coping skills may play a role. Temperament is also a factor; therefore, assessing both environmental, cognitive, and behavioral influences is critical.
Of course, whenever you work with children and adolescents, the role of the family is significant. A thorough assessment of family norms, values, discipline styles, and interaction patterns is a necessary component of the case conceptualization process.
Now that we examined the research and diagnostic categories for the various childhood onset disorders, let’s turn to another case example and case conceptualization.
The Case of Phillip
Example of T/C Case Conceptualization Model Outline
(*designates issues to further explore)
Presenting Problem: difficulty following directions, inattention, distraction, academic problems
Internal Personality Constructs and Behavior:
Self-Efficacy: low
Self-Esteem: low*
Attitudes/Values/Beliefs: low valuing of education
Attachment Style: Parents are involved and concerned*
Biology/Physiology/Heredity: male, 12 years old, siblings also have attention problems, father has ADHD as well, currently prescribed stimulant medication
Affect: distracted, irritable, possible depression
Cognition: Belief that he should be left alone
Hot Thoughts: “Just leave me alone.”
Behavior: loses things, disorganized, “spacy,” wanders around aimlessly, unable to sit still, isolated
Symptomology: irritable, distractible, social isolation
Coping Skills and Strengths: few coping skills, supportive parents
Readiness for Change: precontemplation
Life Roles: student, sibling, son
The Case of Phillip
Phillip is a 12-year-old boy who was recently diagnosed by his family physician with ADHD and prescribed medication. His mother and father came to you for help with Phillip’s behaviors at home and school. Phillip’s father discloses that he also has a diagnosis of ADHD, and reveals that he sees many of his traits in Phillip. Phillip is very messy and unorganized both at school and at home. Phillip’s mom describes him as a “wild child” who does not follow directions. Phillip also has two younger siblings, and his mom describes them all as unable to listen or sit still for more than a few minutes. Mom describes the home environment as “chaotic, where one child just feeds off the other two. We can’t sit down to a family meal or watch a movie or have quiet time to read.” Dad describes Phillip as “spacy” and “in his own little world.”
Phillip’s teachers report that he often appears unaware of what is taking place around him. He consistently daydreams, and doesn’t respond to peers or to the teachers. When the teacher asks what he is thinking about, he responds “I don’t know.” Phillip especially has trouble with self-motivation and written tasks. Phillip is extremely unorganized and spends a great deal of time looking for lost homework, pencils, or his lunch. He makes careless mistakes and seems not to be listening when given instructions. When asked to complete any activity that lasts longer than five minutes, he becomes distracted, often distracting others in the process.
Phillip frequently misplaces things, such as his coat or his lunchbox, and has trouble following even simple directions on where to go or what to do. He does not seem to have any close friends, and usually wanders around aimlessly or daydreams during recess or lunch breaks. He has trouble completing assignments on time or according to the directions, and often forgets to bring the right books to school. Phillip is resentful of the extra attention he gets and would like the teachers and aides to just leave him alone.
Phillip prefers to sit in the back of the classroom, and if allowed, would spend as much time as he could doodling in his notebook or staring out the window. While in the counselor’s office, Phillip spends most of the initial session swiveling and rolling around in the office chair. The counselor habitually has to repeat questions several times, and mom and dad have to continually prompt Phillip to stay on task.
Environment:
Relationships: conflicted relationship with parents, few friends
Culture:*
Family Norms and Values: family values organization and quiet
Societal Influences: school and societal value on organization, quiet
Timeline:
Past Influences: past school experience*
Present Influences: depressed mood, difficulty concentrating, conflicted relationship with parents, siblings*
Future Goals: increased concentration in school and at home, academic success, closer friendships, higher self-efficacy, improved relationships with family
Counseling Keystones
Autism spectrum disorder (ASD), generally referred to as autism, encompasses a group of complex and varying neurodevelopmental disorders that can severely impact a child’s ability to understand and interact with others and their environment.
ASD is characterized by deficits in communications skills and reciprocal communication, repetitive patterns of behavior, and neurological and developmental delays.
The number of cases of ASD has increased drastically over the past few decades, with the most current studies reporting that approximately one child in every 88 could potentially fit the diagnosis.
DSM-5 groups the diagnostic criteria for ASD in two general categories: persistent deficits in communication and interaction across multiple contexts, and restrictive and repetitive patterns of behavior.
Although there may be differences in communication styles and early childhood developmental expectations from culture to culture, those with ASD would be considered out of the norm in any context.
Given the wide variance in symptoms and severity of ASD, there is most likely a complex picture of etiology that includes genetics, brain development, and environmental factors.
Research on ASD has shown that early intervention is key and usually involves several educational, compensatory (helping the child use areas of strength to address areas of need), and behavioral interventions.
Attention deficit/hyperactivity disorder (ADHD) is usually diagnosed before the age of 12 and affects roughly 5% of children.
Diagnostic criteria for ADHD are split into two main areas; the first set of criteria are marked by persistent patterns of inattentiveness, and the second focuses on hyperactivity and impulsivity.
Roughly 60% of children diagnosed with ADHD fit the criteria for another mental health disorder, including mood disorders, such as anxiety and depression, conduct disorder, and language and communication disorders.
Research shows that there is a strong genetic component and that ADHD appears to be highly heritable.
Counseling interventions employed for ADHD typically include behavioral, cognitive behavioral, family-based, and relaxation techniques.
Oppositional defiant disorder (ODD) is characterized by irritability and negativity in almost every setting and evidenced by frequent outbursts and verbal tirades.
To fit the DSM-5 diagnosis for ODD, the child must have regularly exhibited four of the following behaviors: arguing with adults, losing temper, actively defying or refusing to comply with rules or request from authority figures, intentionally behaving in a way that annoys another person, being angry or resentful, being easily annoyed by others, being vengeful or spiteful, and blaming others for their own misbehavior or mistakes.
Studies suggest that roughly 15% to 20% of those diagnosed with ODD also fit the criteria for ADHD.
Most experts believe that there are many contributing environmental and biological risk factors to an ODD diagnosis, including the child’s temperament, developmental delays in cognition or communication, lack of or inconsistent parental support and supervision, previous abuse or neglect, and possible brain chemical imbalances.
Conduct disorder (CD) is exemplified by prolonged periods of anti-social behaviors, the breaking of established rules and social norms, and violations of the law.
Those diagnosed with CD are at a significantly higher risk of meeting the criteria for at least one other disorder, especially substance abuse and impulse-control disorders.
Counseling interventions employed with ODD and CD are usually behaviorally based and focus on appropriately expressing and controlling anger and aggression.
Exercises
EXERCISE 12.1 Making Certain That Language and Communication Styles Are Developmentally Appropriate
CLASS EXERCISE: Small group work followed by large group discussion.
Question 1: Would you change your counseling focus toward certain constructs (i.e. focus more on behavior) when working with children and adolescents? Why or why not?
Question 2: Are there words or phrases that you would typically use with adults that you would not use while working with younger children? Which ones? (Identify 5 to 10)
Question 3: Would you change your nonverbal communication style when working with children? Adolescents? If so, how?
EXERCISE 12.2 Working with Parents, Caregivers, and Home Environments
CLASS EXERCISE: Small group discussion followed by large group discussion.
Question 1: How does working with children change your approach to your role as counselor?
Question 2: How would you work with parents/caregivers? What could be the potential benefits? Potential drawbacks?
Question 3: How is consultation with parents different/similar to the counseling process?
EXERCISE 12.3 Counseling Interventions with Children and Adolescents
CLASS EXERCISE: Individual work followed by large group discussion.
Question 1: In your opinion, what types of interventions might work better with younger children? With adolescents?
Question 2: Using the T/C Case Conceptualization Model, what constructs might you focus on more with children, and which might you emphasize with adolescents? Environment? Cognition? Behaviors? Why or why not?
Question 3: What areas of strength can you focus on when working with children?
The Case of Bill
Sixteen-year-old Bill was brought to the office by his mother because of several incidents at school. The last incident was so severe that Bill is required to have a mental health evaluation and letter before he is able to return to school. Bill was suspended indefinitely for bringing a weapon to school. Bill has also been suspended in the past for marijuana possession, fighting with peers, assaulting a teacher, and misconduct in a bathroom. Mom reports that Bill leaves the apartment for days at a time, does not listen to anything she says or asks him to do, and has stolen money from her purse. She is “at her wits end,” and does not know what to do with him.
Bill says that everything that he does is blown out of proportion. He leaves the house for days at a time after what he calls a “blow out” fight with his mother. Bill’s father is incarcerated and he has no recollection of any significant relationship with him. Bill complains that his mother regularly works at night and on the weekends and leaves him in charge of his two younger siblings.
EXERCISE 12.4 Case Conceptualization Practice Using the T/C Model
See The Case of Bill, above.
CLASS EXERCISE: Small group discussion followed by large group discussion.
Question 1: What is your case conceptualization of this case?
Question 2: What else would you want to know?
Question 3: What would be three possible goals for Bill in counseling?
Go Further
Treatment of Autism Spectrum Disorders: Evidence-Based Intervention Strategies for Communication and Social Interactions edited by Patricia Prelock and Rebecca McCauley (2012) Brookes
Autism Spectrum Disorders: From Theory to Practice by Laura Hall (2012) Pearson
The SAGE Handbook of Emotional and Behavioral Difficulties edited by Philip Garner, James Kauffman, and Julian Elliot (2014) SAGE
Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder by Edward M. Hallowell and John J. Ratey (2011) Anchor
The ADHD Workbook for Kids: Helping Children Gain Self-Confidence, Social Skills, and Self-Control by Lawrence Shapiro (2010) Instant Help
Parenting Children with ADHD: 10 Lessons That Medicine Cannot Teach (APA Lifetools) by Vincent J. Monastra (2005) American Psychological Association
Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program Therapist Guide (Treatments That Work) by Steven Safren, Carol Perlman, Susan Sprich, and Michael Otto (2005) Oxford University Press
Oppositional Defiant Disorder and Conduct Disorder in Children by Walter Matthys and John Lochman (2011) Wiley
Conduct and Oppositional Defiant Disorders: Epidemiology, Risk Factors, and Treatment edited by Cecilia A. Essau (2014) Routledge
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