EVALUATION OF A CHILD WITH DISRUPTIVE BEHAVIOR
When assessing children who exhibit negative behavior, it is important to try to understand the context of the symptoms. It would be helpful if there were a biological test or a psychological test that was reliable and valid for diagnosing any of the disruptive disorders. However, the reality is that the most important aspect of the evaluation process is the psychiatric examination. Table 3 proposes an outline for an assessment focused on understanding a child's disruptive behavior.
When meeting with families who are dealing with severely disruptive behavior, you may find it challenging to take the time necessary to fully understand the depth and breadth of a problem. Our health care system favors rapid assessment and quick interventions; however, at times like this, these are not what is needed. When assessing younger children, it may be prudent to meet with the parents without the child to obtain additional information. Conversely, it may be important in older children or adolescents to meet separately with them to establish rapport before meeting with their parents. After the interview process, a physical examination is indicated to rule out medical causes of disruptive behavior, however rare these may be (Table 4).
Simple assessments, such as vision and hearing tests, can sometimes obviate unnecessary interventions. In older children and adolescents, it is important to assess for substance use, as well as any severe sleep-related difficulties. Exploring the influence of language and cultural factors, when appropriate, may also lead to understandable explanations for behavioral difficulties. ADHD, ODD—or both? Because so many children and adolescents with ADHD receive a diagnosis of ODD, it can be difficult to determine how distinctly separate these 2 disorders are. Newcorn and Halperin6 discuss the challenge of differentiating ADHD from ODD and CD because of considerable symptom overlap; however, they suggest that there is evidence that ADHD and ODD/CD do not represent variations of a single entity. Still, several studies reviewed by these researchers suggest that children with ADHD are at increased risk for the development of ODD and CD. The assessment of a child with ADHD must therefore include a careful assessment of risk factors and protective factors related to ODD and CD (see Table 2). Not only does this process result in a more accurate diagnosis, it provides a starting point for interventions.