Understanding and Managing Adolescent Disruptive Behavior: Page 2 of 3
Understanding and Managing Adolescent Disruptive Behavior: Page 2 of 3
The symptoms of disruptive behavior may be medically induced or induced by substance abuse. All of the following medical conditions may cause disruptive behavior:
• Neurological disorders: traumatic brain injury, seizures (temporal lobe epilepsy), tumors, vascular abnormalities
• Endocrinopathies: thyroid abnormalities (eg, hyperthyroidism)
• Infections: encephalitis/postencephalitic syndromes
• Metabolic disturbances: glucose dysregulation
• Systemic illness: systemic lupus erythematosus, Wilson disease
While these are rare, it is tragic for these potentially treatable illnesses to go undetected. At the University of Louisville Child and Adolescent Inpatient Unit during the past year, we have encountered adolescents whose disruptive behavior was caused by hyperthyroidism (with mood instability and aggression), juvenile Huntington chorea (manifested by cognitive and behavioral changes), and cannabis-induced psychotic disorder.
In addition, drugs can promote externalizing behaviors, such as violence and aggression. Common substances associated with aggression include alcohol, marijuana, cocaine, amphetamines, hallucinogens, phencyclidine, sedatives, inhalants, anabolic steroids, and ecstasy.5
For those DSM-IV disorders that are defined by disruptiveness, uncomplicated ADHD is a model neuropsychiatric disorder that responds to medication intervention and is a clear example of a disease model. Other psychiatric disorders may be comorbid with the disruptive disorders (eg, depression and conduct disorder). In addition, a number of disorders (eg, conduct disorder, ODD, disruptive behavior disorder NOS, ADHD, communication disorders, adjustment disorders, autism and pervasive developmental disorder, mood disorder, PTSD, psychotic disorders) have disruptive behaviors as part of the relevant diagnostic criteria, although the core disorder is not in the disruptive category. In these instances, using approved treatments for the primary disorder often ameliorates the disruptive behavior.
Assessing severity and comorbidities
While identifying disruptive behavior is not particularly difficult, assessing severity and comorbid problems can be challenging. Some of the more common means of identifying externalizing symptoms, such as the Conner Rating Scales or the Child Behavior Checklist, can guide the diagnostic assessment. These assessments can be supplemented by more in-depth psychological examinations (eg, projective testing) to solve a complex differential diagnostic problem, usually to assess a possible thought disorder.
Describing how disruptive youth behave is not the same as understanding why they behave as they do. The challenge for the clinician is to determine if there are unifying elements in understanding disruptive behavior. Are there identifiable developmental pathways that lead to the lack of self-regulation that is so characteristic of disruptive youth? Can these pathways be linked to understanding the family dysfunctions that seem to accompany disruptive behavior?
Both case vignettes illustrate a family interaction model that places children at risk for disruptive behavior. Such a model provides a way to understand the lack of self-regulated behavior, how disruptiveness is maintained, and how the child’s internalized world is formed, and it offers areas for intervention. This approach challenges a contemporary reductionism, whereby impulsivity and aggressive behavior are seen primarily as major mental illness requiring pharmacotherapy.6
J.C. is a white, 13-year-old boy who presented to the outpatient psychiatric clinic, accompanied by his mother. She reported that he no longer respected her authority, was struggling with anger control problems, and had severe outbursts every time she told him “no.” J.C. lives with his single mother and has no contact with his biological father. He has witnessed significant violence between his mother and her abusive boyfriend. Through his early development, his mother gave in to most of his demands, largely because of guilt engendered by the negative impact of her decisions. This deprived and indulged teen acted on any impulse and became violent and aggressive. He had little empathy for his mother; instead, he became the abuser in the relationship. He met criteria for ADHD and conduct disorder of adolescent onset. Because of his mood lability, marijuana abuse, rage, and sense of entitlement, pediatric bipolar disorder had been diagnosed.
The therapist encouraged J.C.’s mother not to accept the disrespectful treatment. However, the mother’s guilt and passive personality impeded her progress. J.C. received common interventions for ADHD and was placed on a low dose of atypical antipsychotic to blunt aggressivity.7
It was difficult for him to engage in psychotherapy and he was often nonadherent with his medication regimen. However, his mother made strides in being more consistent in limit setting. She developed insight, understanding that her inability to set limits was related to her guilt for choosing father figures who were unavailable and even destructive. Perhaps more important, she began to see that her interactions with her son prevented his self-regulation. In individual and family therapy, J.C. was directed to be more respectful of his mother and she was encouraged to demand that respect. This learning process facilitated J.C.’s self-regulation.
A family model of self-regulation
Before describing the model of self-regulation and where it goes awry in families, several points must be made regarding family function. While the ensuing discussion focuses on the role of the environment in self-regulation, biological vulnerabilities (eg, temperament) are important variables in eliciting parenting responses. The clinician must be able to see familial influence in 2 ways:
• Problematic interaction can be elicited by a child.
• Families can create problems for a child. Recent findings show the influence of parental depression on child psychopathology.8,9
Specific epidemiological data indicate that a family intervention may be needed when there is a history of parental drug use, parental criminal behavior, child abuse and/or neglect, parental psychopathology, marital conflict, and single parenting.10
Development is a process of the external becoming internal. The child moves from depending on his parents to regulate essentially all aspects of functioning to gradually taking over and self-regulating more and more of his or her own behavior. This certainly includes developing control over impulses.11
Children listen best to parents with whom they feel safe, and their adherence is linked to pleasing their parents. When a parent is relatively unavailable, a child learns impulsivity and lack of self-control. As one child said, “I cannot wait for my needs to get met because they probably won’t be met.” An environment of relative deprivation fosters a narcissistic viewpoint and a lack of self-regulation. A secure attachment to a caregiver gives a safe context for the trial and error necessary to develop self-regulation in response to stress. A child literally learns how to control himself.
On one hand, when insecure attachment is coupled with harsh, inconsistent parenting, the chances for disruptive behavior are heightened. On the other hand, parental overindulgence that removes roadblocks and mitigates child distress compromises the child’s opportunity to learn to self-regulate responses to frustration. By immediately gratifying a need, the indulgent parent predisposes his child to disruptive behavior and impulsivity: the child is literally prevented from learning how to control himself.
Although the mechanisms remain somewhat unclear, it seems that both types of parental problems in attachment predispose to a disruptive child who becomes angry and labile when experiencing environmental limits. Hence, the frequent presenting complaint from parents: “Doctor, he rages when he doesn’t get his way. He is fine if he gets what he wants.” These children are often clinically narcissistic, with a grandiose, yet fragile, sense of self.
J.P. is a biracial, 12-year-old, adopted boy with a diagnosis of bipolar disorder. He came in for a second opinion consultation because he had not responded to numerous trials of pharmacotherapy (he had been treated with 6 different psychotropic medications since the diagnosis). J.P. refuses to do his homework and often takes hours to do work that could be done in an hour. His father often completes J.P.’s assignments. J.P. justifies his poor performance by complaining that the teachers are mean and “give us work that is too hard.”
When J.P. was adopted, his father was 43 years old and his mother was 40. This middle-class couple showered J.P. with affection and wanted to “see him happy.” As J.P. got older, he passively resisted many developmental challenges, and his parents acquiesced to his demands for assistance. His parents saw J.P.’s behavior as “cute.” His disruptive behavior increased as developmental demands increased. The therapist identified the parental adoration as incompatible with limiting J.P.’s disruptive behavior.
The early stages of treatment involved numerous discussions with the parents to help them understand the disease and available treatments. They were confused about the previous diagnosis of bipolar disorder. While that diagnosis was not summarily dismissed, the clinician helped the family see that J.P.’s problems in self-regulating his behavior had meaning in a family context.
J.P.’s medication was withdrawn with no observable adverse effects. His demand that his parents help him with his homework because it was “too hard” came to be seen for what it was—a significant deficit in the ability to handle stress. The parents worked on their own dynamics—his father thought his son was “cute and humorous” while his mother felt undermined when she attempted to set limits. They developed insight into their indulgence as having roots in J.P.’s adoption as a special, longed-for moment in their lives.
With the family’s consistency in setting limits and increased expectation of accountability, J.P. resisted and became angrier and physically and verbally threatening. His entitled behavior was countered with clear family expectations of self-control. Currently, J.P. has little insight into his own entitled behavior. By doing less for J.P., his family has prepared the way for his acquisition of self-regulation.