Defiant Behavior Research Articles

Innocent or Intentional?: Interpreting Oppositional Defiant Disorder in a Preschool Mental Health Clinic.

Based on 9months of ethnographic fieldwork in a U.S. mental health clinic focused on the treatment of preschool-aged children who exhibited extremely disruptive behavior, this article examines the contradictions clinicians faced when trying to identify and attribute "intentionality" to very young children. Disruptive, aggressive behavior is one of the central symptoms involved in a wide-range of childhood psychopathology and the number one reason young children are referred to mental health clinics in the United States. In the clinic where I conducted my research, clinicians were especially interested in diagnosing these children with oppositional defiant disorder (ODD), in order to identify those at risk for more serious mental illness later in the lifecourse. In this article, I look at the different strategies clinicians used in interpreting whether aggressive, defiant behavior was a part of the child's "self," a biologically driven symptom of a disease, or a legitimate reaction to problematic social environments. I argue that conceptualizing intentionality as a developmental, interpersonal process may help to make sense of the multiple discourses and practices clinicians used to try to reconcile the contradictions inherent in diagnosing ODD.

Family Functioning and Predictors of Runaway Behavior Among At-Risk Youth.

Adolescent runaway behavior is associated with a host of negative outcomes in young adulthood. Therefore, it is important to understand the factors that predict running away in youth. Longitudinal data from 111 at-risk families were used to identify proximal predictors of runaway behavior over a 12-week period. On average, youth were 14.96 years old, and 45% were female. Ten percent of youth ran away during the 12-week follow-up period. In bivariate analyses, running away was predicted by poorer youth- and parent-rated family functioning, past runaway behavior, and other problem behaviors (e.g., substance use, delinquency), but not poorer perceived academic functioning. Results of a hierarchical logistic regression revealed a relationship between youth-rated family functioning and runaway behavior. However, this effect became non-significant after accounting for past runaway behavior and other problem behaviors, both of which remained significant predictors in the multivariable model. These findings suggest that youth who run away may be engaged in a more pervasive pattern of problematic behavior, and that screening and prevention programs need to address the cycle of adolescent defiant behavior associated with running away. Recommendations for clinical practice with this at-risk population are discussed.

Measuring positive and negative aspects of youth behavior: Development and validation of the Adolescent Functioning Scale

This paper outlines the development and validation of the Adolescent Functioning Scale (AFS) in an Australian sample of parents of young people aged 11–18 years (N = 278). The AFS, a parent self-report measure, was designed to assess problem behavior and positive development in adolescents. Principal components analysis produced a 33-item measure comprising four subscales: Positive Development, Oppositional Defiant Behavior, Antisocial Behavior and Emotional Difficulties. Convergent validity was established via correlations between the AFS and established measures of adolescent functioning and parenting, and discriminant validity was shown through no association between the AFS and a measure of technology use. Internal consistency for the subscales was high (H = .82–.92 for different age groups), as was test-retest reliability (r = .77–.86). The study indicated that the AFS is a potentially valuable tool for assessing levels of problem behaviors and positive development in adolescents.

COMORBID DISORDERS OF ATTENTION DEFICIT HYPERACTIVITY DISORDER IN CHILDREN

In the article on the basis of a survey of 86 children the problem of comorbidity with attention deficit hyperactivity disorder, which are found in 69.8% of patients and lead to additional complications of intra-family, school and social adaptation. The structure is characterized by the presence of comorbid disorders, oppositional defiant behavior disorders (43.0%) and various forms of anxiety disorders (39.5%). At 9.3% of children with the disease have met tics, 17.4% - nocturnal enuresis and 5.8 - faecal incontinence.

Evaluating the effectiveness of combining Home-Start and Triple P parenting support in the Netherlands

The effects of Home-Start compared to Home-Start extended with Triple P group training were studied. The underlying theoretical models of change of both programs complement each other and therefore it was assumed that combined support leads to increased positive outcomes. Outcomes related to parental wellbeing, parenting behaviour and child behaviour were included. One hundred forty four parents, all mothers, were randomly assigned to either the Home-Start program or the combined support of Home-Start and Triple P group level 4. Parents reported on wellbeing, parenting behaviour, and child behaviour at baseline, post-program and at 6-month follow-up. Based on intention to treat analyses, families in the combined intervention condition showed similar effects on the majority of primary and secondary outcomes as the only receiving Home-Start condition. A negative effect on parental depression and on two subscales of the Child Behavioral Checklist (anxiety and oppositional defiant behaviour) was found for families in the combined Home Start and Triple-P condition. The hypothesized stronger positive effect of combining Home-Start and Triple P support on selected outcome measures was not confirmed. Combining promising evidence-based parenting programs with complementary underlying theoretical frameworks does not necessarily lead to better results.

The Process and Implications of Diagnosing Oppositional Defiant Disorder in African American Males

Research studies indicate that the number of African Americans diagnosed with oppositional defiant disorder (ODD) is disproportionately higher than other demographic groups (Feisthamel & Schwartz, 2009; Schwartz & Feisthamel, 2009). One contributing factor for this disproportionality is that White American clients presenting with the same disruptive behavioral symptoms as African American clients tend to be diagnosed with adjustment disorder. Feisthamel and Schwartz (2009) concluded, perceive attention deficit, oppositional, and conduct-related problems as significantly more common among clients of color (p. 51), and racial diagnostic bias may influence the assessment process. Racial biases in clinical decision making are explained in a conceptual pathway developed by Feisthamel and Schwartz (2007).In the pathway, counselors who hold stereotypical beliefs about clients selectively attend to client information. The counselor's judgment is influenced by personal bias, resulting in misdiagnosing the client. African American masculinity stereotypes of criminal mindedness, violent behavior, aggression and hostility (Spencer, 2013) held by counselors with low multicultural social justice counseling competence (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015; Sue, Arredondo, & McDavis, 1992) potentially foster misdiagnosis and overdiagnosis of African American males with ODD.Studies on how African American males are diagnosed with ODD and specific implications for African American males are relatively nonexistent. McNeil, Capage, and Bennett (2002) indicated the majority of information on children diagnosed with ODD has been obtained from primarily White children and families. They recommended that counselors working with African American families consider the African American family's unique stressors, worldviews and burdens; possible inclusion of the extended family; possible therapist biases that conflict with client's worldview; and positive factors that lead to competency, self-reliance and health in African American culture (Lindsey & Cuellar, 2000). Thus, an appropriate ODD diagnosis in African American males requires assessment and treatment plan considerations that include other related factors.Diagnosing Oppositional Defiant Disorder in African American MalesAccording to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013), ODD is characterized by a pattern of behavior that includes angry and irritable mood, argumentative and defiant behavior, and/or vindictiveness. Symptoms must cause significant problems at home, school or work; must occur with at least one individual who is not a sibling; and must persist for 6 months or more (APA, 2013). The diagnostic assessment also determines that (a) these behaviors are displayed more often than is typical for peers, and (b) symptoms are not associated with other mental health disorders such as anxiety, depression, antisocial behavior and substance abuse disorders.High rates of ODD diagnosis among African American males may occur because of low cultural competency in diagnosis and counselor bias (Guindon & Sobhany, 2001; Hays, Prosek, & McLeod, 2010; Snowden, 2003). Spencer and Oatts (1999) and Clark (2007), for example, found that health professionals misinterpreted symptoms of disruptive behavior disorders like ODD at greater rates for African American children. Misdiagnosis was common among children assessed as having symptoms of (a) obsessive compulsive disorder and response to rigid classroom rules, (b) bipolar disorder or attention-deficit/hyperactivity disorder and engagement in destructive behavior, and (c) anxiety disorder (e.g., social anxiety) and dislike for school, and defiance toward teachers. These symptoms also may result from unfair treatment and discrimination (Smith & Harper, 2015). Misdiagnosis of ODD can reasonably be expected to have potentially adverse implications for healthy psychological, emotional and social development in family and education systems. …

Predicting Depression and Anxiety from Oppositional Defiant Disorder Symptoms in Elementary School-Age Girls and Boys with Conduct Problems.

This study investigated the relationship between the three DSM-5 categories of oppositional defiant disorder (ODD) symptoms (irritable mood, defiant behavior, vindictive behavior) and anxiety/depression in girls and boys with conduct problems (CP) while controlling for comorbid child psychopathology at baseline. Data were drawn from an ongoing longitudinal study of 6- to 9-year-old French-Canadian children (N=276; 40.8% girls) receiving special educational services for CP at school and followed for 2years. Using linear regression analysis, the results showed that irritable mood symptoms predicted a higher level of depression and anxiety in girls and boys 2years later, whereas the behavioral symptoms of ODD (e.g., defiant, vindictive symptoms) were linked to lower depression scores. The contribution of ODD symptoms to these predictions, while statistically significant, remained modest. The usefulness of ODD irritable symptoms as a marker for identifying girls and boys with CP who are more vulnerable to developing internalizing problems is discussed.

The impact of caregiver treatment satisfaction upon child and parent outcomes.

Parental perceptions about treatment influence their child's engagement in and ongoing utilization of mental health services, but less is known about the association between caregiver expectancies and family outcomes. The literature is particularly lacking with families of color, who are at high risk for the onset and perpetuation of disruptive behaviors. The purpose of this study was to examine caregiver treatment satisfaction amongst 320 youth of color aged 7 to 11 and their families who were assigned to either a Multiple Family Group intervention or services as usual condition. Caregiver stress was measured by the Parenting Stress Index Short-Form full scale and child oppositional defiant behaviors were measured using the Iowa Connors Rating Scale-Oppositional/Defiant subscale both at baseline and post-test. Satisfaction with treatment was measured using the Metropolitan Area Child Study process measures program satisfaction subscale at post-test. The two main effects models that focused on satisfaction with treatment was predictive of parental stress and child oppositional defiant behaviors independently. Satisfaction with treatment accounted for 31% of the variance in child oppositional behavior and 24% of parental stress improvements across time holding all covariates constant. Our findings support previous research that shows parental expectancies, including treatment satisfaction, are powerful mechanisms of treatment outcomes for children with DBDs as well as parental emotional health. Further, parental expectancies may be enhanced by the involvement of families in the development of treatment approaches for children and a greater focus on caregiver emotional health for the benefit of the family as a whole.

The Eyberg Child Behavior Inventory: Factorial invariance in problem behaviors across gender and age.

The Eyberg Child Behavior Inventory (ECBI) assesses problem behaviors in children, and is a widely used instrument in both clinical work and research. Evidence suggests that the short ECBI version, comprising 22 items, can be reduced into the three oblique factors: Oppositional defiant behavior; Conduct problem behavior; and Inattentive behavior. The present study aimed to evaluate this three-factor model in a Norwegian sample of 554 children, and examine multi-group invariance across gender and age. Consistent with previous research, results confirmed a tripartite model, with the same residual covariances and cross-loading appearing across groups. Multi-group confirmatory factor analysis demonstrated partial measurement invariance across gender and age. Overall, findings support a meaningful comparison of the short ECBI across gender and age. The study makes a contribution to the generalizability issue of the ECBI.

The Protective Effects of Social Factors on the Academic Functioning of Adolescents With ADHD

There is considerable evidence that externalizing disorders such as attention deficit/hyperactivity disorder (ADHD) put youth at risk for a range of adverse academic outcomes. It is importantly to note that some youth avoid these negative outcomes, yet there is a gap in our understanding of these resilient youth. The purpose of this study was to longitudinally evaluate social acceptance and social skills as potential protective factors of the associations between inattentive, hyperactive/impulsive, and oppositional defiant behaviors with academic outcomes. Participants included a sample of 93 middle school students comprehensively diagnosed with ADHD. Parents and adolescents completed ratings of social skills and perceived social acceptance. School grades and teacher-rated academic impairment were assessed 18 months later as longitudinal academic functioning outcomes. Inattention and social acceptance were associated with academic outcomes 18 months later. Regression analyses revealed that parent- and adolescent-rated social acceptance demonstrated promotive effects for grades and against teacher-rated academic impairment. Further, social acceptance significantly interacted with inattention in predicting school grades, such that high parent- and adolescent-rated social acceptance significantly attenuated the relationship between inattention and poor grades, even after controlling for baseline grades and intelligence. The presence of social acceptance was especially critical for adolescents with high levels of inattention. Specifically, adolescents with high inattention and high social acceptance had a mean grade point average of 2.5, and adolescents with high inattention and low social acceptance had a mean grade point average of 1.5. These findings demonstrate that social acceptance may be an important intervention target for improving academic outcomes among adolescents with ADHD.

Atatürk in the Nazi Imagination. By Stefan Ihrig. Cambridge, MA: Harvard University Press, 2014. Pp. 311. Cloth $29.95. ISBN 978-0674368378.

Central European History vol. 39, no. 1. BOOK REVIEWS book is often chaotic, lacks clear development, is repetitious, and makes irrelevant jumps through time—all of which, in the end, needlessly blur his narrative. L EO VAN B ERGEN R OYAL N ETHERLANDS I NSTITUTE OF S OUTHEAST A SIAN AND C ARIBBEAN S TUDIES doi:10.1017/S0008938916000224 Ataturk in the Nazi Imagination. By Stefan Ihrig. Cambridge, MA: Harvard University Press, 2014. Pp. 311. Cloth $29.95. ISBN 978-0674368378. It is rare to read a work of history that is both startling and true, but Ataturk in the Nazi Imagination is both. Reading through “hundreds, perhaps thousands” (194) of texts published in German newspapers between 1919 and 1945, Stefan Ihrig has discovered the German Right’s “obsession” (14, 27) with Turkey, which culminated in a Mustafa Kemal Ataturk cult comparable to that of the Turkish Republic. The atmosphere of the Nazi movement was “saturated with ‘Turkey’” (101), and articles on Turkey outnumbered those on all other countries combined. As Ihrig points out, one finds almost nothing about Turkey in studies of National Socialism. Yet, as early as 1920, Turkey was repeatedly depicted on the Right as a “role model” (Vorkampfer) for Germany. Ihrig’s readings of the “media frenzy” (151) over Turkey’s War of Independence are es- pecially incisive. Given the German elites’ traditional philhellenism, some papers had initially favored Greece, but eventually all of them turned against it, as seen in their lopsided com- mentary on the massacres committed on both sides, and in their admiration for Turkey’s defiant behavior at the 1923 Conference of Lausanne. By overturning the 1920 Diktat forced on Turkey in Paris, Team Ankara had won German hearts. What explained Turkey’s success? Turkey had a Fuhrer who had, ignoring the Ottoman leadership in Constantinople, established his own government on the periphery (Ankara), stamped an army out of the ground, and, through sheer force of will, reconquered Anatolia from its Greek and Armenian minorities and their French allies: “a revisionist-nationalist dream come true” (11). Turkey was a “‘parallel Germany,’ where things went the way they were supposed to” (64). Ataturk abolished opposition parties, introduced an autarchic economy, and ruled an ethnically cleansed, racially pure population of farmer-warriors. The New Turkey was everything the Weimar Republic was not. Ihrig revises our picture of National Socialism in a number of ways. He topples Benito Mussolini from his pedestal as a source of Adolf Hitler’s inspiration. Until the Italian alliance in the 1930s, il Duce was barely mentioned in the Nazi press. By contrast, Ataturk, as Hitler would later proclaim and his press endlessly repeat, was the German leader’s “star in the dark- ness” during the long years before 1933. In arguing that Turkey mirrored the Nazi utopia, Ihrig casts a skeptical eye on the recent thesis that Nazis thought themselves Christian: crush- ing the “churches” (i.e., Islamic institutions) was “an integral ingredient, if not one of the preconditions” (225) of Turkey’s success. Ihrig’s most exciting chapter is his second, “Ankara in Munich,” on the 1923 Beerhall Putsch. In the run-up to November 9, 1923, Heimatland, the organ of Bavaria’s paramilitary

Occult abdominal infection and psychiatric symptoms: A case report

Introduction The clinical presentation of numerous infectious processes can include diverse Subtle cognitive dysfunction or mood change (e.g., irritability), depression, psychosis and delirium are the most likely symptoms to occur and may result from a small focus of chronic infection. Aims Disclose an unusual clinical case with symptoms as the first presentation of an infection. Methods The review was based on scientific documentation published in PubMed database, journals and reference textbooks. We used the following terms as keywords occult infection and psychiatric symptoms. Results We present the case of a 48-year-old woman without history until January 2015, time when she had insidiously developed personality changes with emotional instability. Five months latter, during her stay in urgency department after her second suicide attempt, her dysphoric mood, defiant behaviour and persistent suicidal ideation were interpreted as a personality disorder that has led to a compulsory admission. Forty-eight hours after the admission, she became febrile with fluctuation of consciousness and ended up being transferred with sepsis to an intensive care unit. The carried out investigation has shown an abdominal infection, i.e. peritoneal abscesses without isolated infectious agent. With the resolution of the infectious process, the symptoms subsided and she returned to her premorbid personality level. Conclusions Infectious diseases can firstly present with Timely investigation of the underlying etiology for symptoms that persist after conventional treatments is crucial for appropriate intervention and full recovery of the patient.

The Preliminary Study of the Relationship Between Emotion Regulation Difficulties, Callous-Unemotional Traits and the Emergence of Oppositional Defiant Disorder in Outpatient Adolescents

Background: Previous research has demonstrated that oppositional defiant is a strong predictor of mental illness that cause significant distress for adolescents who manifest the disorder and pose remarkable costs for society. Objectives: The aim of this study was to investigate the role of callous-unemotional traits and emotion regulation diculties in pre- dicting oppositional defiant disorder. Materials and Methods: This is a descriptive-correlative study performed on a sample of 320 male high school students, chosen via multi-stage random sampling. Instruments used to collect data are inclusive of oppositional defiant behavior inventory (ODBI), di- culties in emotion regulation strategies scale (DERS) and inventory of callous-unemotional traits (ICU). Results: The results suggest a significant relationship between oppositional defiant behavior, impulse control diculties and callous- ness. Regression analysis revealed that 16% variance of oppositional defiant behavior can be explained by impulse control diculties and callousness. Conclusions: Our findings highlight the importance of callousness and impulse control diculties in development of oppositional defiant disorder. Moving forward, clinicians should consider the importance of these variables in their future research to identify mech- anism through which callousness and impulse control diculties enhances risk of oppositional defiant disorder.

Sitting on a stability ball improves attention span and reduces anxious/depressive symptomatology among grade 2 students: A prospective case-control field experiment

This study used a prospective matched case-control design to examine the effects of sitting on a stability ball on inattention, hyperactivity, oppositional defiant behaviours, and anxious/depressive symptomatology among 23 experimental and 18 control grade 2 students. Classroom teachers completed the NICHQ Vanderbilt Assessment Scale at baseline and 8-weeks (T2) and 5-months (T3) after the experimental group switched to stability balls. Social validity was assessed at year-end. ANCOVAs controlling for baseline scores demonstrated that students in the experimental condition had improved attention at T2 and T3 and reduced anxious/depressive symptoms at T2. All students and the classroom teacher preferred the balls. In conclusion, sitting on stability balls is well received and may represent an effective classroom management strategy for improving attention.

North Korea's Politics: Path of Reclusive Tyranny

Kim Jong-un's obsession with full control of power and his single-minded pursuit of nuclear advancement, as seen in the fourth nuclear test in January 2016, have further isolated his country. North Korea apparently is taking a revisionist strategy: to change the rule of the game in Northeast Asia and in inter-Korean relations. North Korea exploits the Chinese dilemma of condemning the defiant behaviour but cannot abandon the country.

Participatory Action Research with Filipino Street Youth: Their Voice and Action against Corporal Punishment

The study investigated perspectives on corporal punishment of adolescents from street families in Manila, with the aim of creating actions that address the issue in that specific context. Participatory action research (PAR) was employed as a research design, collecting qualitative data with 11 youth, selected through purposive sampling. Results showed that harsh corporal punishment is highly normative in that context, most frequently physically and emotionally abusive, and often co‐occurs with verbal abuse. It has negative effects on the youth's feelings towards, and their relationship with, their parents, and it leads to defiant behaviours. The youth planned an action project to address the issue of corporal punishment in their families: producing a video clip and holding a parents' meeting. Through the PAR process, the youth were empowered to voice their feelings and perceptions and to take action to address the issue of corporal punishment in their families and in the wider community. The study demonstrated how PAR can serve as a pathway towards empowerment for a very vulnerable group.‘Investigated perspectives on corporal punishment of adolescents from street families in Manila’Key Practitioner Messages: Little is known about children's perceptions related to corporal punishment, and children remain powerless to address this issue which most often happens in the intimate family context. Harsh corporal punishment is a highly normative experience for street youth in Manila, and is often physically and verbally abusive. The PAR process served as a pathway to empowerment for the youth, enabling them to address the issue of corporal punishment in their context. ‘Little is known about children's perceptions related to corporal punishment’

Teacher-Reported Irritable and Defiant Dimensions of Oppositional Defiant Disorder: Social, Behavioral, and Academic Correlates

Previous research suggests that the symptoms of oppositional defiant disorder (ODD) reflect both a general diagnostic construct and two distinct symptom dimensions, irritability and defiant behavior. Recent studies have found that these two symptom dimensions exhibit different patterns of correlates and outcomes (e.g., irritability linked to depressive symptoms, defiant behavior linked to conduct problems). The present study investigated common and unique correlates of the irritable and defiant dimensions of ODD symptoms in a sample of 706 school-age children (49 % female, ages 5–12) in grades K-5. Classroom teachers rated their students’ ODD symptoms, proactive and reactive aggression, relational and physical aggression and victimization, withdrawn/depressed symptoms, peer rejection, and academic performance. Multilevel regression models—controlling for grade level, gender, and shared variance between symptom dimensions and variable subtypes—showed that teacher-reported irritability and defiant behavior exhibit common correlates of physical and relational aggression, relational victimization, and peer rejection. With respect to differential correlates, irritability was uniquely associated with physical victimization and withdrawn/depressed symptoms, whereas defiant behavior was uniquely associated with proactive aggression and hyperactive–impulsive symptoms. Further, reactive aggression was more strongly linked to irritability than to defiant behavior. These findings provide further support for a multidimensional conceptualization of ODD symptoms within the school context and suggest that irritability and defiant behavior have important implications across several domains of children’s social–emotional development.

Restrictive Mediation and Unintended Effects: Serial Multiple Mediation Analysis Explaining the Role of Reactance in US Adolescents

Extant research indicates that restrictive parental mediation, parents enforcing rules limiting children’s media use, produces unintended effects in adolescents. Speculation exists that these suboptimal effects are due to psychological reactance following a restrictive mediation interaction leading the adolescent toward defiant behavior. A survey of undergraduate students (N = 483) was conducted to investigate the process of psychological reactance as a mediating factor in the relationship between restrictive parental mediation and three unintended effects: negative attitude toward parents, positive attitude toward restricted content, and increased viewing of restricted content with friends. Results revealed a direct effect of restrictive mediation on attitude toward parent, but not attitude toward restricted content or viewing restricted content with friends. Moreover, the reactance process fully mediated restrictive mediation’s effect on attitude toward restricted content and viewing restricted content with friends, and partially mediated the effect on attitude toward parents.

Parenting Styles, Parenting Practices And Adhd: Predicting Oppositional Defiant Behaviour In School And Home Setting

The present research aimed at investigating the relationship amongparenting styles, parenting practices, attention deficit hyper activity disorder (ADHD) and oppositional defiant behaviour (ODB) among school going boys. The study hypothesizes a) a positive relationship among authoritarian, permissive parenting styles, relevant practices and ODB while negative relationship between authoritative parenting styles and ODB in school as well as home settings, b) positive relationship between ADHD and ODB in school as well as home settings and c) ODB will be predicted from parenting styles, parenting practices and ADHD. The reporting participants about boys (N=200) included teachers (N=40) and parents (N=400).The ODB & ADHD was measured by Child and Adolescent Disruptive Behaviour inventory (Burns, 2010) and parenting styles by Parenting Styles and Dimensions Questionnaire (Robinson, Mandelco, Olsen, & Hart, 2001). Authoritarian/ permissive styles were significantly correlated with ODB and fathers’ permissiveness, authoritative style and ADHD came out to be significant predictors, differentially across two settings.

Acute Psychosis in an Adolescent Treated With Infliximab for Crohn's Disease.

To the Editor: Infliximab is a monoclonal antibody against tumor necrosis factor-α (TNF-α) and has been shown to be 81% more efficacious than placebo in Crohn’s disease patients who have had an inadequate response to conventional therapy.1 While there are case reports of suicide attempts after treatment with infliximab for inflammatory bowel diseases,2,3 and reports of anti–TNF-α treatment leading to psychosis in elderly patients with rheumatologic disorders,4 to our knowledge, this is the first case of a pediatric patient with Crohn’s disease who developed acute psychosis after treatment with infliximab. Case report. A 15-year-old white male high school honors student, with a history of Crohn’s disease since age 12 years and a history of obsessive-compulsive disorder and attention-deficit disorder, received his first 3 infliximab infusions over a 2-month period for treatment of poorly controlled Crohn’s disease. One month after the third infusion, his teacher and parents noticed odd changes in his personality, which included inappropriate verbal outbursts, increased agitation, and defiant behavior over the course of 2 days. He then became verbally threatening and combative with his mother and was brought to the emergency department. In the emergency department, he was seen by psychiatry staff and found to have disorganized thought process with loose associations, echolalia, delusions of thought broadcasting and grandeur, distractibility, and severe psychomotor agitation. He had no history of recreational drug or alcohol use. Extensive workup results were all within normal limits including a head computed tomography scan, brain 3 magnetic resonance imaging, routine electroencephalograph, Lyme Western blot, urinalysis, lumbar puncture, cerebrospinal fluid culture, serum herpes simplex virus polymerase chain reaction, rapid plasma reagin, vitamin B12, folate, thyroid-stimulating hormone, stool culture, stool ova and parasite, and urine toxicology screen. The patient was started on haloperidol, which was titrated to 1 mg twice a day. Although this tempered his agitation and aggression, his psychosis did not completely resolve, and he experienced an acute dystonic reaction that led to the discontinuation of the medication. He was discharged home but came back in a few days for worsening behavior along with agitation and abusive speech. Treatment with olanzapine titrated to 7.5 mg twice a day resulted in resolution of his psychotic symptoms. However, on the fourth day of olanzapine treatment, a fourth infliximab infusion was administered, and shortly after, he suddenly became agitated and combative and appeared to experience visual hallucinations. The infliximab treatment was terminated, and he was discharged home with outpatient follow-up. At present, olanzapine has also been discontinued. He attends weekly group therapy at an outpatient facility and has returned to his normal mental status. Given the timing of his initial presenting symptoms within the 3 months of his initial infliximab infusions and the immediate relapse of psychotic symptoms after his fourth infliximab infusion, we believe that the patient’s psychosis is best explained by a psychotic reaction to infliximab. He was consistently psychotic with no fluctuations of consciousness to suggest coincidental delirium, and no substance-induced cause was identified. It is interesting to note that his psychosis responded better to an atypical neuroleptic compared to a typical one. There is evidence that atypical neuroleptics inhibit activated microglia release of proinflammatory cytokines, especially nitric oxide and TNF-α.5 Anti–TNF-α therapy has numerous well-recognized adverse events, such as infection and malignancy. However, there is very little information in the literature pertaining to psychiatric side effects. We suggest that patients treated with infliximab for Crohn’s disease could experience an acute psychosis. Treatment with an atypical antipsychotic may be considered over the typical antipsychotics. However, more controlled prospective studies are required to confirm our suspicion of causality between infliximab and psychosis to guide treatment.