James Donaldson on Mental Health - Disruptive Behavior: Why It's Often Misdiagnosed

Tantrums and defiance may mask issues that aren't apparent to teachers and parents

Clinical Experts: Vasco Lopes, PsyD , Laura Prager, MD , Nancy Rappaport, MD

What You'll Learn

- Why is disruptive behavior often misdiagnosed?

- What are some of the reasons kids have tantrums?

- How can parents tell what’s causing kids’ disruptive behavior?

- Quick Read

- Full Article

- The common diagnosis: ODD

- Anxiety disorders

- ADHD

- Learning disorders

- Sensory processing problems

Many people assume that kids who act out or throw tantrums are angry or defiant. Sometimes they are diagnosed with oppositional defiant disorder (ODD) as a result. But that diagnosis might be wrong. Instead, kids’ disruptive behavior might be caused by a different disorder that’s easier to miss. 

One possibility is that your child could have an anxiety disorder, which makes it hard for them to handle stressful situations. For example, they might refuse to do what you ask or try to run away because they’re scared. Or, if they have social anxiety, they might scream at another child if socializing gets too stressful. 

ADHD is another option. Kids with?ADHD have a hard time controlling their impulses and tend to grab things from other kids. They also find it hard to wait their turn and frequently interrupt others. Plus, they have a hard time focusing on schoolwork and don’t like being bored. When these struggles cause disruptive behavior, it’s often misunderstood as defiance. 

If your child mostly acts out in school, they could have an undiagnosed?learning disorder. They might lash out or refuse to follow directions because they’re frustrated by schoolwork. Or they might be trying to hide their struggles by getting teachers to focus on their behavior instead. 

Finally, your child might be struggling with sensory processing issues. When they’re overwhelmed, kids with sensory issues can react in ways that look extreme. They might do things like scream if their face gets wet or melt down if there are bright lights, loud noises or a crowd. Some kids will even run away from places that make them uncomfortable. 

Most children have occasional temper tantrums or emotional outbursts, but when kids repeatedly lash out, are defiant, or can’t control their tempers, it can impair their functioning in school and cause serious family turmoil.

The first challenge in helping a child manage their behavior better is to understand why they’re doing what they’re doing. In the same way that a headache or a fever can be caused by many things, frequent outbursts — which clinicians call “emotional dysregulation”— can reflect a number of different underlying issues.

It’s easy to jump to the conclusion that a child who’s pushing or hitting or throwing tantrums is angry, defiant or hostile. But in many cases disruptive, even explosive behavior stems from anxiety or frustration that may not be apparent to parents or teachers.

Here we take a look at some of the diagnoses that are associated with disruptive behavior in children. It’s crucial to understand what’s really behind the childhood behavior problems in order to treat them effectively.

The common diagnosis: ODD

Often children who lash out or refuse to follow direction are thought to have oppositional defiant disorder, which is characterized by a pattern of negative, hostile, or defiant behavior. Symptoms of ODD include a child frequently losing their temper, arguing with adults, becoming easily annoyed, or actively disobeying requests or rules. In order to be diagnosed with ODD, the disruptive behavior must be occurring for at least six months. But there are a number of other issues that could lead to kids being oppositional or out of control in school or at home.

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Anxiety disorders

Children with anxiety disorders have significant difficulty coping with situations that cause them distress. When a child with an untreated anxiety disorder is put into an anxiety-inducing situation, they may become oppositional in an effort to escape that situation or avoid the source of their acute fear.

For example, children with acute social anxiety may lash out at another child if they find themselves in a difficult situation. Children with OCD may become extremely upset and scream at their parents when they do not provide the constant repetitive reassurance that they use to manage obsessive fears.

We tend to associate anxiety with kids freezing, avoiding things they’re afraid of, or clinging to parents, notes says Rachel Busman, PsyD, a clinical psychologist. “But you can also see tantrums and complete meltdowns.”

“Anxiety is one of those diagnoses that is a great masquerader,” explains Laura Prager, MD, director of the Child Psychiatry Emergency Service at Massachusetts General Hospital. “It can look like a lot of things. Particularly with kids who may not have words to express their feelings, or because no one is listening to them, they might manifest their anxiety with behavioral dysregulation.”

ADHD

Many children with ADHD, especially those who experience impulsivity and hyperactivity, may appear to be intentionally oppositional. These children may have difficulty sitting still, they grab things from other kids, blurt out inappropriate remarks, have difficulty waiting their turn, interrupt others, and act without thinking through the consequences.

These symptoms are more a result of their impaired executive functioning skills—their ability to think ahead and assess the impact of their behavior—than purposeful oppositional behavior.

In a recent study conducted by Amy Roy, PhD, of Fordham University, more than 75 percent of children who presented with severe temper outbursts also fit the criteria for ADHD. That doesn’t necessarily mean they’ve been diagnosed with ADHD — in fact the disorder may be overlooked in kids who have a history of aggression.

“What people don’t understand is that a lack of focus, an inability to complete work and tolerate boredom, among other symptoms, can contribute to the escalation toward the explosive outbursts,” explains Vasco Lopes, PsyD, a clinical psychologist. So you have to get to the underlying cause.”

Learning disorders

When a child acts out repeatedly in school, it’s possible that the behavior stems from an undiagnosed learning disorder. Say they have extreme difficulty mastering math skills, and laboring unsuccessfully over a set of problems makes them very frustrated and irritable. Or they know next period is math class.

“Kids with learning problems can be masters at being deceptive — they don’t want to expose their vulnerability. They want to distract you from recognizing their struggle,” explains Nancy Rappaport, MD, a Harvard Medical School professor who specializes in mental health care in school settings. “If a child has problems with writing or math or reading, rather than ask for help or admit that they’re stuck, they may rip up an assignment, or start something with another child to create a diversion.”

Paying attention to when the problematic behavior happens can lead to exposing a learning issue, she adds. “When parents and teachers are looking for the causes of dysregulation, it helps to note when it happens — to flag weaknesses and get kids support.”

Sensory processing problems

Children who have trouble processing sensory information can have extreme and sometimes disruptive behavior when their senses are feeling overwhelmed. They might do things like scream if their faces get wet, throw violent tantrums whenever you try to get them dressed, crash into walls and even people, and put inedible things, including rocks and paint, into their mouths.

Besides tantrums and mood swings, kids with sensory processing issues are also at risk for running away when an environment becomes too overwhelming for them. The “fight or flight” response can kick in when kids are feeling overloaded with sensory input, and their panicked reactions can put them in real danger.
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