ODD-CD part 8

Charlene is 14, too.  Her life didn't start out quite so difficult.  In fact, her mom swears that until she was almost 10, there were no problems.  That is hard for everyone to believe now.  Her mom remembers thinking that Charlene was certainly starting the teen years early.  At age 11 she was having a tantrum about not being able to go out with her boyfriend who was 15.  You could hardly blame her.  By the time Charlene was 11, she looked like she was 15 or 16.  Unfortunately, she did not have the maturity of a 16 year old.  She ran away from home at age 12 for a week before they could find her.  She brought a bottle of rum to school and got drunk.  But more than this, she was absolutely unbearable to live with.  She had become super defiant, and would fight her parents or anyone else for no reason at all.  She never seemed happy, just angry.  Unless she was with her friends, which by age 13 or 14 were 18 or so.  Her parents kept asking themselves, "what had happened to their old daughter? "  She was failing in school mostly because she was never there.  She was never where she told her parents she said she was.  The first clue came when she came home high on something and told her parents she was going up stairs to bed.  They heard a crash and came in the bathroom to find her trying to cut herself with a broken mirror.  Charlene wanted to die.  Her boyfriend of two months had left her.  For a few weeks she just hung around the house and laid on her bed and listened to music.  Her parents let her out one night to go to her girlfriend's house.  They got a call later that night that Charlene had admitted to taking a half a bottle of Tylenol.

It is not uncommon that a mood disorder along with CD gets missed.  There are usually so many pressing problems to sort out and so many different stressors, that it isn't until suicide is tried or talked of that many families, physicians, and other health professionals consider comorbid depression.  Recent studies of teenagers who have committed suicide have found that these children are about three times more likely to have CD and 15 times more likely to abuse substances.  Suicide is worth worrying about in CD.

Marc is now 12.  He has seen more doctors, nurses, and psychologists than most people will see in a lifetime.  His father worried that maybe his son could have Tourette's like him, but he never dreamed it could get like this.  When he was 4 he was thrown out of pre-school for fighting.  Because of his reputation, he was the first child where the school approached the parents about getting a teacher's aide in grade primary rather than the parents approaching the school.  Lucky for Marc, he never seemed to have all of these problems at once.  Usually he would have a tic, especially blinking, which would last a few weeks or so.  Then he would have to touch things, and then that might go away, too.  The tics and OCD were nothing compared to his behavior.  His temper was incredible.  The usual pattern was that the excitement of being around other kids would get him so wound up that he was literally bouncing around.  This usually led to pushing, fighting, and punishment.  He resisted this and usually ended up being sent home as they could not deal with him.  He attacked him sister.  He attacked his mother and broke her arm.  That led to living with different relatives and now a foster home.  No one seemed to be able to manage him.  The new foster parents were actually being bothered the most by his poor sleep and a nearly constant vocal grunting tic.  They brought him to yet another doctor to see if they could do anything about this.  He was placed on some medicine for the tic and amazingly, he behavior improved quite a bit.  For the first time his parents are hopeful that maybe he can come home again.

This is one of the "labels" psychiatry uses to describe people who have traits in their personality that cause them major problems.  These are not things that come and go but last for decades.  A person's personality starts to form as a teenager, and that is when we see personality disorders start to form.  We have all met people with these types of problems.  They fit into a few big categories that have lots of different names.

One group is people who are strange, different, and keep to themselves.  Another group is people who are dramatic, have lots of mood problems, are forever getting into trouble, and whose lives are quite mixed up.  They are often very difficult to get along with over the long run.  Another group are people who are withdrawn, scared, and have to do things a certain way.  When any of these problems screw up people's relationships, ability to work, get them in trouble with the law, or make them miserable, we call it a personality disorder.  Why is this important?  If you have another psychiatric problem along with a personality disorder, it is a lot harder to get better.  For example, a person with depression and a personality disorder is less likely to get better than a person who just has depression.

Recent studies have shown that children who have certain psychiatric problems are much more likely to get personality disorders as adults.  Children who have multiple psychiatric problems are even more at risk.  Children who have ODD are about four times more likely to have a personality disorder when they grow up, that is about a 15% chance.  If they already have some signs of personality disorder as a young teenager, they are 25 times as likely to have a personality disorder as adults.  What this tells us is that the longer these problems go on in childhood and as teenagers, the more likely they are to lead to personality disorders as adults.

When Tina was four or five, she pretty much controlled the house.  Somehow she had figured out exactly what she could get away with.  She also was able to figure out where her parent's weak points were.  More amazingly, she figured out where the weak points in their marriage were.  This got so bad that her parents went to marriage counseling and finally adopted a policy of "united we stand, divided we fall" in regards to Tina.  This certainly helped keep Tina in line in her elementary school years.  Tina also had ADHD, but it was never too severe.  She only had to take medication for a few years at the end of elementary school.  As she became a teenager, she began to have problems.  The loss of a boyfriend led to cutting her wrists.  She always was in some sort of turmoil with her friends or the youth group.  People were always trying to "save" her.  The school counselor and the youth group leader both "knew in their hearts" that Tina needed a lot of attention and special care and encouraged her parents to be more understanding on her sensitive nature.  Tina's grandfather said that he "knew in his heart" that Tina needed a swift kick in the rear.  As the teenage years went on these problems just continued.  She got involved in some minor crimes like shoplifting, tried vomiting to lose weight, and smoked pot.  Each time she made such a big deal about the whole thing that her parents could hardly stand it.  When she was 18, she moved in with an older guy who she thought "really understood her".  They have been separated about six times so far.  Her life continues in turmoil.

This points out the fact that sometimes, even with great parenting, things don't turn out so well.  However, many times with aggressive intervention things go more like this-

Richard was always hyper and always quite the con artist.  The neighbor hood mom's never really trusted him.  He got referred after he hit the teacher hard enough to knock her down in second grade.  We did everything.  He took medications for his ADHD.  The parents followed through with every time of intervention for ODD.  He was very involved in cadets as a teenager.  When he was about 19 I met his mother in a store.  She wanted to tell me how well he turned out.  He was still a bit of a hot head and was still on meds for ADHD, but he was working and had a steady girlfriend.  He was hoping to join the militia.  Richard had turned out just fine.