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Q After several years of successful treatment of ADHD with methylphenidate hydrochloride (Ritalin) or the amphetamine Adderall, many children seem to develop oppositional defiant disorder (ODD) or conduct disorder (CD). Might these disorders be a delayed effect of the medication? Also, what drugs do you recommend for ODD and CD? Could these problems be related to bipolar disorder?
Wm. B. Rogers, MDCuyahoga Falls, OH
A These questions are complex because the causes of ODD and CD are not well defined. No biochemical or other central nervous system abnormality explains these disorders, which are very commonly seen with ADHD. I am not aware of literature supporting the idea that ODD or CD develops after ADHD is treated with medications, linking the disorders to these specific therapeutic interventions. We do know, however, that at least 30% to 40% of children with ADHD will also be diagnosed with ODD, and as these children grow older, many of them will "earn" a diagnosis of CD. I have often seen children as young as 3 or 4 years who have ODD when they are diagnosed with ADHD. In fact, I believe that ODD frequently precedes the diagnosis of ADHD.
Normal development in the teen years is more likely than the effects of ADHD medication to explain observations. Children approaching and beyond puberty become more oppositional and independent. I always explain to families that children diagnosed with ODD at an early age will almost invariably become much worse as they move into adolescence. What you are seeing are the natural behavior changes in a child from 11 to 14 years old, but magnified in a child who has ODD and, of course, CD.
Although psychostimulant medications do not specifically address the symptoms of ODD or CD, they often make the children with these diagnoses less impulsive. Thus, patients are less likely to display oppositional and conduct problems while they are taking the medication. As to medications meant for ODD, there are no good studies showing that any available medication is specific for this diagnosis. For an extremely aggressive child, you might try one of the medications used for aggressive behavior that cuts across diagnostic lines. The a II agonists such as clonidine and guanfacine used to be considered quite good for this purpose, but I've come to believe that these drugs do not affect ODD and CD directly; rather, by making the child tired, they alleviate oppositional tendencies. Other antiaggression drugs include the tricyclic antidepressants, the serotonin reuptake inhibitor (SRI) antidepressants, other antidepressants such as trazodone, and some of the newer antipsychotics such as risperidone and molindone. Other possibilities are some of the b blockers, such as propanalol, and the mood stabilizers such as lithium, carbamazepine, and valproic acid. Valproic acid and lithium, in particular, still are at the top of the list for children with disruptive behavior disorders, even without a diagnosis of a mood disorder.
Medications for treating OCD in children are the same as those used in adults: SRI antidepressants (fluvoxamine, especially, has been studied in children) as well as clomipramine and clonazepam and, in rare cases, some of the antipsychotic drugs such as risperidone. Combinations of drugs are often necessary to treat OCD, along with behavioral therapy.
Current research studies are addressing whether these problems, especially the aggressive disorders, are related to bipolar disorder. Many investigators believe that children who are very irritable and oppositional and who have angry outbursts and behavioral meltdowns may be exhibiting the childhood equivalent of bipolar disorder. If this is the case, the condition could be treated with mood stabilizers, as detailed above. Other observers think this diagnosis is made too frequently, and we should be more careful about how we presecribe these medications.
I strongly believe that multiple psychopharmacologic agents should be avoided. Try to handle disruptive behaviors with behavioral and family interventions, if at all possible.
Martin Baren, MDOrange, CA
DR. BAREN practices educational, behavioral, and developmental pediatrics.
Q A 31/2-year-old girl in my practice refuses to share her toys with her friends but plays with her friends' toys when she visits them. The child's mother wants advice on changing her daughter's behavior. The little girl is healthy and developmentally normal for her age.
Muhammad Waseem, MDBronx, NY
A Nearly all children from 3 to 5 years of age are in a necessary yet challenging stage of development in which they view the world only through their own eyes. They feel entitled to all benefits and responsible for all events and outcomes, and generally are more sensitive to their own needs and desires than to those of others. Thus, asking the child how she would feel if her friend would not share with her is unlikely to cause enduring ethical reflection. The universal impulse for self-centered behavior at this age is exaggerated in the child who is highly persistent, has a low sensory threshold, is intense and slow to adapt, or has a negative attitude.
Whatever the child's innate behavioral style, her caregiving experience can facilitate or hinder her capacity for sharing and taking turns, and your patient seems to be blessed with a positive parent role model. That the mother seeks your advice on this matter suggests that the child's family values, and therefore models, mutual caring and respect in their relationships. A few gentle questions about the child's primary care-giving relationships, in child care or preschool as well as at home, should alert you to any problems these influences may be creating in this child's life.
Sometimes a child acts selfishly because she is having difficulty adjusting to some unexpected or unwanted alteration in her life. When did the behavior become bothersome? Is the family system changing? Is there a new pregnancy or sibling, a change in a parent's work schedule or marriage, a recent move or different bedroom for the child? Are there any other sources of stress in the family's lives? If not, help the parents encourage the emotional rewards of social behavior. They should notice and praise spontaneous acts of kindness and sharing. In addition, the parent should tell her daughter when they are alone together, especially at bedtime, how proud she is of her for a specific act of sharing earlier in the day.
The parent should calmly redirect the child who has a lapse in social grace while playing with a friend--if the children can't resolve the tension themselves. You might suggest that the parent join her daughter and a friend in play for a brief time, guiding them toward social reciprocity. Teaching and learning the personal rewards of sharing creates a secure foundation of lifelong emotional health for parents and children alike.
Peter A. Gorski, MD, MPABoston, MA
DR. GORSKI is President, WellChild Foundation, Boston, MA, and Assistant Professor of Pediatrics, Harvard Medical School, Boston.
Q The mother of a 2-week-old in my practice is still nursing her 4-year-old several times each day in addition to nursing the newborn. The infant is showing excellent weight gain. Is this situation detrimental to either child? How long is too long to nurse a child?
Mario M. Sangillo, MDHarrisburg, PA
A It is almost universal for older infants or toddlers, especially those recently weaned, to show an interest in drinking from the breast after a new sibling is born. If the mother responds with mild surprise but allows a taste, this interest is usually short lived and is merely a test of the mother's continued availability to the older child. If the mother seems shocked or reluctant, breastfeeding is more likely to become a source of jealousy and to inspire misbehavior. If this second scenario seems to be the cause of the situation you describe, the mother might welcome behavioral advice.
The only medical considerations for the infant are to assure an adequate share of milk (which is unlikely to be a problem since breast milk is well established) and the risk of infection if the breast is not cleaned, from secretions left on the breast by the older child. The medical considerations for the mother are caloric depletion, long-term calcium depletion, and exhaustion.
A much greater consideration is the psychological reasons for the mother's choice to breastfeed both children since in this country it is unlikely to be a nutritional necessity. If the mother is unable to separate from the older child or to frustrate her by setting limits on continued nursing these issues are likely to be problems for the child in other areas, such as separation for sleep or preschool, compliance with adult requests, and willingness to use the toilet. If the parents view nursing as essential for the older child's health, they may have extreme views on diet that require monitoring. Another possibility is that they view the child as vulnerable, which can cause problems in behavioral adjustment and the child's self-concept as well as with general development of skills and autonomy.
Given the situation, it is important to assess the health of the relationship between the parents. Determine the father's views on the decision to breastfeed the older child; it may be that it is solely the mother's choice and that she is defying her spouse, perhaps to keep the children closer to her and away from him.
If the older child is developing normally and shows adequate independence and compliance, and the relationship between the parents and the infant and between the parents seems adequate, you should condone the nursing.
Barbara Howard, MDBaltimore, MD
DR. HOWARD is Assistant Professor of Pediatrics, Johns Hopkins University School of Medicine, and Co-Director, Center for Promotion of Child Development Through Primary Care, Annapolis, MD.
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Marian Freedman. Behavior: Ask the experts. Contemporary Pediatrics 1999;10:39.