Mental Health

Oppositional Defiant Disorder

Many parents have been shocked at least once by a formerly cooperative teen resisting the house rules, talking back, or otherwise acting defiantly, but this type of behavior may just be part of normal growing up. More is required for a diagnosis of Oppositional Defiant Disorder.

Why Oppositional Defiant Disorder Is Difficult to Understand

There are two main guides to health issues and disorders that are used to guide the diagnosis of Oppositional Defiant Disorder (ODD). Whereas in many cases, these two resources present a similar view of disorders, in the case of Oppositional Defiant Disorder, the categorization is at odds, and this, in addition to a complicated definition, makes it difficult to understand what Oppositional Defiant Disorder is.

The DSM-IV-TR View of Oppositional Defiant Disorder

The Diagnostic and Statistics Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) includes Oppositional Defiant Disorder as a subcategory of Attention-deficit and disruptive behavior disorders, along with Attention-Deficit Hyperactivity Disorder, Conduct Disorder, and Disruptive Behavior Disorder NOS (Not Otherwise Specified).

Diagnosing ODD using the DSM-IV-TR criteria, which can only be done by mental health professionals who are qualified to do so,is only after determination that the criteria for Conduct Disorder are not met and, if the person is 18 or older, that criteria for Antisocial Personality Disorder are not met.

In that case, the individual must demonstrate a pattern of behavior that has lasted at least 6 months and shown at least four of the following signs or symptoms:

• frequently losing temper

• frequently argues with adults

• frequently defying or refusing to cooperate with the requests or rules of adults

• frequently annoying others on purpose

• frequently scapegoating others for his or her own mistakes or misbehavior

• frequently showing a high degree of sensitivity and touchiness with others

• frequently acting angry and resentful

• frequently acting spiteful or vindictive.

In addition, the behavior disturbance must:

• be more frequently that is normal for other individuals of similar age and development;

• cause “clinically significant impairment” in at least one area of life, whether academic, social, or occupational;

• not occur solely as the result of a psychotic disorder or mood disorder.

According to the Surgeon General’s website, Oppositional Defiant Disorder is sometimes considered a “precursor of conduct disorder.”

ICD-10 View of Oppositional Defiant Disorder

The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) takes a different approach to Oppositional Defiant Disorder than the DSM-IV-TR. It includes it under the category “Behavioral and emotional disorders with onset usually occurring in childhood and adolescence” within the subcategory “Conduct disorders.” The other members of the category are:

• Conduct disorder confined to the family context

• Unsocialized conduct disorder

• Socialized conduct disorder

• Other conduct disorders

• Conduct disorder unspecified.

As you can see, it is the only member of the category that does not have conduct disorder in its name. The subcategory “Conduct disorders” is separate from the following category, called “Mixed disorders of conduct and emotions,” which addresses the limitation in the DSM-IV-TR diagnostic criteria that rules out behavior that is only present in connection with a mood disorder or psychotic disorder.

The ICD-10 diagnosis, which specifically says that it usually occurs in “younger children,” begins with a child meeting the criteria for Conducts disorders generally. This requires that the pattern of behavior–whether dissocial, aggressive, or defiant—be both repetitive and persistent, as well as well outside age-appropriate expectations, and last six months or longer. If the behavior can be explained by a different psychiatric diagnosis, that explanation should be preferred.

Given that those criteria are met, one goes on to the specific Oppositional Defiant Disorder criteria, which limits the characterization of the behaviors to acts that are “defiant, disobedient, disruptive,” but not delinquent, extremely aggressive, or extremely dissocial, nor merely extremely mischievous or naughty.

The Upshot of Differing Understandings

A research study published in 2005 found that some children who were diagnosed with Oppositional Defiant Disorder using the criteria of ICD-10 as described above received no DSM-IV diagnosis, and this is a problem. The study suggested ways of addressing the situation.

If this comparison does nothing else, it will hopefully equip parents whose child is being considered for an ODD diagnosis, has been ruled out from having such a diagnosis, or has already received such a diagnosis to be able to discuss the criteria whereby the child’s behavior was analyzed and ask knowledgeable questions.


Physical Problems

Teen Smoking

Teen smoking had been on a sharp decline since the mid-late 1990’s, but recent data shows that the adolescent smoking rates are rising slightly.

According to a 2005 study done by the CDC, 23% of high school students reported smoking cigarettes in the last month. This is compared with a previous study of high school students that showed 21.9% in 2003. While this data is somewhat discouraging it is far better than the 1997 level of the same survey at 36.4%. The rise appears to be greatest among white and Hispanic teens while the rates of teen smoking declined among black teens.

There is no concrete evidence at this time to show why the teen smoking statistics have declined since 1997, but some believe it is in better awareness efforts. Some also feel that it is due to a decline in media glamorizing smoking.

The CDC study showed that 80% of smokers begin before the age of 18. A similar study which was published by the American Lung Association website shows 90% of smokers begin before the age of 21.

A study that was done by the CDC also found some interesting facts and estimates:
1. About 3,900 teens under 18 start smoking each day.
2. Of the 3,900 teens that start smoking each day – 1500 will become regular smokers.
3. Those who smoke often have secondary behavioral issues such as violence, drug/alcohol use, and high-risk sexual behavior.

Some of the contributing factors of teenage smoking are:
1. Low socioeconomic status
2. Use or approval of smoking by siblings/peers
3. Smoking by parents
4. Availability and price of tobacco
5. Lack of parent support / involvement
6. Lower self-image or self-esteem

Consequences of teen smoking:
1. Chronic cough – if smoking is continued
2. Reduced stamina
3. Bad breath
4. Yellow teeth
5. Stinky clothes
6. Expensive habit – 1 pack/day = about $1000/year.

Some tips for parents to help prevent teen smoking:
1. Educate your child about the dangers of smoking early on.
2. Be a good example. Only 2 percent of smokers have parents who don’t smoke. (Mayo Clinic).
3. Don’t leave cigarettes where children or teens may have access to them.
4. Teach the teen or child refusal skills

The CDC reports more recent teen smoking statistics, from a 2012 survey, that reports nearly identical numbers to the 2005 statistics. Results show 23.3% of high school students confirming their use of some type of tobacco product at least once in the last 30 days. Statistics confirm that males are more likely than females to use tobacco products, but the gap is narrowing. From 2011 to 2012 there was a significant increase in the use of electronic cigarettes among both middle school and high school students. Traditional cigarettes continue to be the most widely used form of tobacco product but the most significant increase of use from 2011 to 2012 was seen in nonconventional tobacco products like electronic cigarettes (ecigs) and hookahs.

Teen Smoking Statistics Sources: CDC, Mayo Clinic, ALA

Mental Health

Conduct Disorders

Why Conduct Disorder Is Difficult to Understand

The two primary guides to diagnosing disorders, both of which are used in the diagnosis of Conduct Disorder are the Diagnostic and Statistics Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10).

In some cases, the two guides have a similar analysis of disorders and how they relate to each other. In the case of conduct disorder, however, the two views are different, complicating understanding.

The DSM-IV-TR View of Conduct Disorder

The DSM-IV-TR lists Conduct Disorder as a subcategory of “Attention-deficit and disruptive behavior disorders,” along with Oppositional Defiant Disorder, Attention-Deficit Hyperactivity Disorder, and Disruptive Behavior Disorder NOS (Not Otherwise Specified). There are three specific subcategories of Conduct Disorder, distinguished by the time of onset: in childhood, during adolescence, or unspecified.

Diagnosing Conduct Disorder using the DSM-IV-TR criteria, which should only be done by qualified mental health professionals. If the person is 18 or older, a diagnosis of Conduct Disorder cannot be given unless the criteria for Antisocial Personality Disorder are not met.

The descriptions make it clear that this is a more serious disorder than Oppositional Defiant Disorder. For a diagnosis, the person must demonstrate a pattern of behavior that has included three or more symptoms of those listed below for at least the past 12 months and shown at least one in the past 6 months:

• Aggression towards people and animals

  • frequently bullies, threatens, or intimidates
  • frequently initiates physical altercations
  • has employed a weapon capable of causing serious physical harm
  • has shown physical cruelty to people
  • has shown physical cruelty to animals
  • has confronted and stolen something from a victim
  • has forced sexual activity on someone

• Property destruction

  • has set at least one fire meaning to cause notable damage
  • has purposely destroyed property in some other way

• Deceit or theft

  • has forcibly entered someone else’s house or car without permission
  • frequently lies, conning others
  • has stolen items without a confrontation

• Serious rule violations

  • has frequently broken the house rules and stayed out at night, since before age 13
  • at least twice has stayed away from home overnight without permission or once for an extended period
  • has frequently been truant from school, since before age 13. 

In addition, these behavior disturbances must:

• result in “clinically significant impairment” in either academic, social, or occupational functioning;

If Childhood-Onset type is diagnosed, at least one characteristic must have manifested prior to age 10, whereas is Adolescent-Onset is diagnosed, there must be an absence of manifestation of any of the behaviors prior to age 10. The severity can be designated as mild, moderate, or severe.

ICD-10 View of Conduct Disorder

ICD-10 takes a different approach to Conduct Disorder than the DSM-IV-TR. It includes Conduct Disorder under the category “Behavioral and emotional disorders with onset usually occurring in childhood and adolescence” and designates six subcategories, which are:

• Conduct disorder confined to the family context

• Unsocialized conduct disorder

• Socialized conduct disorder

• Oppositional Defiant Disorder (ODD)

• Other conduct disorders

• Conduct disorder unspecified.

So ODD is a subset of Conduct disorder in the ICD-10 analysis, but not in the DMS-IV-TR analysis, and the category of Conduct Disorder is subdivided in a completely different way, based not on age of onset, but on other specifics of how it manifests.

Diagnosis of any of the ICD-10 subgroups requires that a child first meet the criteria for Conduct disorders generally. This means that the pattern of disruptive behavior–which may be dissocial, aggressive, or defiant—must both be repetitive and persistent, notably beyond outside age-appropriate expectations, and last for six months or longer. If a different psychiatric diagnosis explains the symptoms, that diagnosis should be used.

The further criteria that separate the subcategories are:

• Conduct disorder confined to the family context occurs only or almost only in the home and with members of the family or household.

• Unsocialized conduct disorder is marked by serious abnormalities in relationships between the child and other children.

• Socialized conduct disorder is diagnosed when a person gets along well with peers, and is generally characterized by delinquent activities as a group, or gang, as well as truancy.

• Oppositional Defiant Disorder is usually diagnosed in younger children and the behaviors demonstrated are better characterized as disobedient, defiant, and disruptive rather than delinquent, dissocial, or aggressive.

Understanding a Diagnosis of Conduct Disorder

If you or someone you know has a child who has received a diagnosis of conduct this order, you can use the information in this article to ask questions and find out more. Which type of conduct disorder has been diagnosed and according to which definition? Which criteria were met to support the diagnosis?


Mental Health

Bipolar Disorder

Teen Bipolar Disorder

Bipolar disorder is an illness that can have serious impacts on teens and their families. Teen bipolar disorder, also known as manic-depressive disorder, causes teens to experience extreme moods, known as mania and depression. Mania causes a teen to feel overly energetic and irritable, while teens suffering from depression feel sad, tired, and unable to do anything. Scientists do not yet fully understand teen bipolar disorder, but it seems to be caused by chemical imbalances in the teen’s brain. Teen bipolar disorder cannot be cured, but it can be treated with therapy, and sometimes medications.

Teens with bipolar disorder experience intense moods, often without a clear cause. They may change rapidly from mania to depression, or experience one extreme or the other with long periods of normal or less extreme moods in between. These mood changes are more severe and extreme than the normal ups and downs that every teen experiences. Sometimes stress, medications, or environmental factors can trigger a manic or depressive episode, but the exact causes of bipolar disorder are not yet known. Bipolar disorder seems to have a genetic component, and teens whose close family members have bipolar disorder are more likely to develop bipolar disorder.

Commons signs of mania include:

  • High energy
  • Irritability
  • Violent outbursts
  • Excessive, rapid talking, often jumping from one topic to another
  • Inability to concentrate
  • Little need for sleep
  • Poor judgement, sometimes leading to spending sprees, drug use, or sexual promiscuity
  • Obsession with sexuality
  • Grandiosity, which is an unrealistic sense of one’s abilities, such as thinking one has special powers. Many young people like to imagine having special abilities, have trouble evaluating risk, or exaggerate their own unique talents and skills; this generally only becomes a symptom if the teen tries to act on the ability, like trying to fly. 

Episodes of depression can cause:

  • Prolonged sadness or boredom
  • A feeling of emptiness
  • Loss of interest or energy
  • Headaches and body aches
  • Changes in sleeping or eating habits
  • Fatigue
  • Feeling worried, hopeless, guilty, or anxious
  • Suicidal thoughts or behavior 

Some teens with bipolar disorder show signs of mania and depression in the same day, sometimes even at the same time, such as feeling depressed, but engaging in manic activities. Other teens with bipolar disorder never have severe manic episodes, only minor episodes known as hypomania. Teens who suffer from bipolar disorder may deny that they have a problem, especially while experiencing mania. Some other signs of teen bipolar disorder can include:

  • Poor performance in school
  • Talking or thinking about running away
  • Using drugs or alcohol
  • Engaging in self-destructive behaviors, such as fighting
  • Becoming isolated
  • Being overly sensitive
  • Delusions or hallucinations
  • Thinking about or attempting suicide 

Because doctors are just beginning to understand teen bipolar disorder, they are not yet sure of the number of teens who suffer from it, but about 10 million Americans have bipolar disorder. Many adults who develop bipolar disorder begin to show symptoms in their late teens, but researchers believe that bipolar disorder may begin much younger in some individuals.

A teen who may have bipolar disorder should visit a doctor, who can make sure the teen does not have another medical condition such as attention deficit hyperactivity disorder (ADHD), conduct disorder, or substance abuse problems. A doctor or therapist can recommend and provide treatments for teen bipolar disorder. Treatment may consist of counseling, often combined with a mood stabilizing medication. The use of medication by teens should be monitored carefully; while it helps many people, it may cause suicidal thoughts and behavior in teens.

Families can help teens with bipolar disorder by:

  • Understanding, and helping the teen to understand, that he or she has an illness, and that this illness is not the teen’s fault, but that he or she can do things to feel better.
  • Enrolling in family therapy.
  • Seeking help for any other untreated mental illnesses in family members, such as depression or anxiety; this sets a good example and reduces stress in the family.
  • Providing a quiet environment for the teen, with a regular schedule, especially for sleep.
  • Being patient; avoid telling your teen to “snap out of it” or “get over it.”
  • Always taking talk of suicide seriously and seeking immediate medical help for suicidal teens; be especially alert after a traumatic event like moving, divorce, death in the family, or loss of a friendship or boyfriend or girlfriend. 

Some things teens with bipolar disorder can do to reduce symptoms include:

  • Follow any treatments prescribed by your therapist or doctor
  • Consider keeping a daily journal of your thoughts and feelings
  • Learn ways to manage stress, such as yoga, deep breathing exercises, going for walks, or listening to soothing music
  • Exercise, eat a balanced diet, and get enough sleep
  • Avoid drugs, alcohol, and caffeine, which is found in coffee, tea, energy drinks, chocolate, and many sodas
  • Ask for help when you feel you need it 

Teens with bipolar disorder are at increased risk for suicide. A teen who is having suicidal thoughts or actions should get medical help immediately, or call 911 or a suicide prevention hotline, such as 1-800-SUICIDE (1-800-784-2433); check your phone book for local suicide prevention hotlines or mental health centers.

National Institute of Mental Health, “Bipolar Disorder” [online] and Healthwise, “Bipolar Disorder in Childhood” [online]
National Alliance on Mental Illness, “Bipolar Disorder” [online]
Nemours Foundation, TeensHealth, “Bipolar Disorder” [online]
Kowatch, et. al., “Treatment Guidelines for Children and Adolescents With Bipolar Disorder,” Journal of the American Academy of Child and Adolescent Psychiatry, 44:3, March 2005 [online]

Physical Problems Troubled Teen Issues

Underage Drinking

Even though drinking by anyone under the age of 21 is illegal in the U.S., people aged 12 to 20 years drank 11% of all alcohol consumed in the United States this year. Of this amount more than 90% was consumed in the form of binge drinking. Binge drinking is typically defined as five or more drinks consumed on one occasion and is one way to determine heavy alcohol use. On average 28.3% of underage drinkers (10.8 million persons aged 12 to 20) used alcohol in the past month. Research has shown that underage youth drink more than those of a legal age (4.9 drinks vs. 2.8 drinks).

Legal Drinking Age

  • The legal drinking age for different countries varies dramatically, from 0 to 21
  • 10 countries have no minimum drinking age
  • 13 countries have a minimum drinking age of 16
  • 43 countries have a minimum drinking age of 18
  • 1 country has a minimum drinking age of 19
  • 2 have a minimum drinking age of 20
  • The U.S. has the highest minimum drinking age at 21, but there are many exceptions to this general rule, that lead to underage drinking. 

Drinking and Driving

A yearly average of 4.2 million young people between the ages of 16 and 20 reported driving under the influence of alcohol or illegal drugs during the past year.

Among high school students in the last 30 days:

  • 45% drank some amount of alcohol.
  • 26% binge drink.
  • 11% drove after drinking alcohol.
  • 29% rode with a driver who had been drinking alcohol.

Underage, teen drivers are more likely than older drivers to ride with an intoxicated driver and are more likely to drive after drinking alcohol or using drugs. The number of deaths in motor vehicle accidents involving alcohol, account for 38.6% of all traffic deaths. Reports show 6,002 young people ages 16-20 died in motor vehicle crashes in 2003.

Underage Drinking Deaths

Approximately 5,000 deaths of people under the age of 21 are the result of underage drinking each year:

  • 1,900 deaths from motor vehicle crashes
  • 1,600 as a result of homicides
  • 300 from suicide
  • Hundreds more die from other injuries such as falls, burns, and drownings while they are intoxicated 

This is a big concern because reports show there were approximately 7.2 million people under the legal drinking age who were binge alcohol users in the last month.

Physical Problems

Teen Alcohol Use

Teen alcohol use, underage drinking, and teen alcoholism info from : SAMHSA National Household Survey on Drug Abuse Stats


Underage Drinking Stats for all youth, ages 12-17:

7.2 million adolescents drank at least once in the past year
2.7 million teens drank alcohol about once a month or more in the past year
1 million youths drank at least once a week or more in the past year
Girls were as likely as boys their age to drink alcohol
Hispanic youth were as likely as white non-Hispanic youth to be current drinkers
Black non-Hispanic youth were the least likely of the racial/ethnic groups to be current drinkers
66% thought drinking 4 or 5 alcoholic drinks nearly every day was a great risk
47% thought drinking 4 or 5 alcoholic drinks once or twice a week was a great risk

Teen Alcohol Use for all youth, ages 12-17:

13% had at least one serious problem related to underage drinking in the past year
6% had built up tolerance to the effects of alcohol
3% reported psychological problems related to their teen drinking
1% reported health problems related to their teen alcohol use

Youth, ages 12-17, who drank any alcohol in the past year:

39% had at least one serious problem related to drinking in the past year
18% had built up tolerance to the effects of alcohol
8% reported psychological problems related to their teen drinking
4% reported health problems related to their teen alcohol use

Youth, ages 12-17, who drank alcohol heavily (5 or more drinks on 5 or more occasions in the past month):

77% had at least one serious problem related to underage drinking in the past year
63% had built up tolerance to the effects of alcohol
20% reported psychological problems related to their teen drinking
12% reported health problems related to their teen drinking

Young adults, ages 18-20, who drank heavily (5 or more drinks on 5 or more occasions in the past month):

66% drove under the influence of alcohol in the past year
42% often drove or rode without wearing a seat belt

Young adults, ages 12-20, rates of teen alcohol use in 1998:

Among youth ages 12-20, the rates of teen alcohol use were highest among those 18-20, among whites, male and among those living in the North Central region of the United States. The lowest rates of teen alcohol use were among blacks, females, and youth living in large metropolitan areas.

The rates of current, binge, and heavy teen alcohol use did not change significantly between 1994-1998. Rates were 30.6%, 15.2%, and 6.9%, respectively, for current, binge, and heavy alcohol use.

Physical Problems



The current understanding of Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactivity Disorder (AD/HD—this is the current favored spelling) is that the first is a subset of the second, which is an overarching category that describes three specific disorders and others that have not been typed. The placement of the slash is meant to indicate that hyperactivity is not a manifestation in every type of AD/HD.

There are three distinct categories of symptoms in AD/HD, and the particular symptom or combination of symptoms is what leads to the diagnosis of a particular type of AD/HD. The three symptom categories are hyperactivity, impulsivity, and inattention. This is true for teens as well as younger children.

Parents should be aware that each of these symptoms may be present to a lesser degree than in AD/HD as a component of normal behavior at particular stages of child development. The fact that impulsivity, for example, is a characteristic of AD/HD subtypes does not mean that all impulsivity is abnormal or indicative of a disorder. But whereas children in the normal range learn to limit their impulsivity children with AD/HD need additional help and attention to control and direct their impulsivity.

The way that these symptoms appear with AD/HD is as follows:

• Children with predominantly hyperactive-impulsive subtype have symptoms of hyperactivity and impulsivity, but do not have issues with attentiveness.

• Children with predominantly inattentive subtype (the name that is now used to mean the same thing as Attention Deficit Disorder was in the past) are inattentive, but not hyperactive or impulsive.

• Children with combined subtype exhibit hyperactivity, impulsivity, and inattentiveness—all three of the symptoms.

• Children may also have AD/HD not otherwise specified. This is used when a child has issues with one or more of the three symptoms to a degree that is not developmentally appropriate but does not meet the diagnostic criteria for any of the three defined subtypes.

Statistics on AD/HD

In 2008, the Center for Disease Control (CDC) issued a report stating that approximately five percent of American children age 6 to 17 have been diagnosed with AD/HD, according to parental reports. Because the study only covered diagnosed cases, the incidence is likely to be higher. The study found that boys were twice as likely to be diagnosed with AD/HD as girls, and that teens were more likely to have been diagnosed than were younger children.

Diagnosis of AD/HD for Teens

The diagnostic criteria for AD/HD is not different for teens than for younger children. The criteria require the existence of six symptoms of either inattention or  six symptoms of hyperactivity-impulsivity.

In either case, the symptoms must have been present for a minimum of six months, and be present to a degree that is developmentally inappropriate and causes some impairment of function. At least some of the symptoms must have been present prior to age seven, and the effects must be apparent in at least two settings, such as both at home and at school. In the case of hyperactivity-impulsivity, the symptoms must also be disruptive.

These limitations help to avoid diagnosing temporary behaviors that might be a response to a particular finite situation and resolve in several months. They also help differentiate AD/HD from an athletic, exuberant, or occasionally day-dreaming child.

The symptoms of inattention include careless mistakes, trouble focusing, seeming not to listen, lack of follow through, trouble with organization, avoidance of long tasks, frequent losing or misplacing of possessions, distractibility, and forgetfulness.

The symptoms of hyperactivity-impulsivity include fidgeting or squirming, inability to stay seated for long periods, restlessness, inability to do activities quietly, “Energizer Bunny” energy, excessive talking, interrupting, difficulty waiting, and intrusive behavior.

Help for Teen AD/HD

If you suspect that your child may have AD/HD, the first thing you need is a diagnoses to make sure that the symptoms are not indicative of some other issue. This can be done by a health care provider, such as a pediatrician or psychologist.

Treatment of AD/HD will vary somewhat depending on which of the types is diagnosed. Depending on the situation, a combination of medication and behavioral therapy may be suggested.

If you live in Florida, you might be interested in the study of Teen ADHD at the Florida Clinical Research Center in Bradenton/Sarasota LI. If so, you can get more information here: