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Disruptive Behaviour Disorders

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Title: Disruptive Behaviour Disorders


1
Disruptive Behaviour Disorders
  • Donna Dowling
  • Child Adolescent Psychiatrist
  • Townsville CAYAS

2
  • ADHD ( ADD)
  • Oppositional Defiant Disorder
  • Conduct Disorder

3
Epidemiology
4
Epidemiology
  • Around 3-5 of schoolchildren display ADHD, as
    many as 90 of them boys
  • Worldwide studies consistent not just western
    disease
  • Many children show a lessening of symptoms as
    they move into adolescence
  • At least half continue to have problems
  • One-third of those affected have symptoms into
    adulthood

5
Aetiology
6
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Aetiology
  • Heritability is the strongest factor in
    development of ADHD
  • Risk factors account for only a small portion of
    variance
  • Pregnancy variables young maternal age, maternal
    use of tobacco and alcohol, toxaemia,
    post-maturity and extended labour
  • Medical factors fragile X syndrome, G6PD
    deficiency, phenylketonuria, brain trauma, lead
    poisoning, malnutrition

8
Main Neurotransmitters in ADHD
  • Dopamine
  • Noradrenaline
  • To regulate the inhibitory influences in the
    frontal-cortical processing of information

9
Dopamine
  • - enhances signals - improves
  • . attention, . focus vigilance, .
    acquisition, . on-task behaviour and cognition

10
Noradrenaline
  • dampen  noise 
  • decrease distractibility and shifting
  • improve executive operations
  • increase behavioural, cognitive, motoric
    inhibition

11
Aetiology
  • ADHD symptoms and a diagnosis of ADHD may
    themselves create interpersonal problems and
    produce additional symptoms in the child
  • Some children sensitive to colourings/preservative
    s not sugar per se

12
Diagnosing ADHD
13
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14
Inattention symptoms
  • Fails to give close attention careless mistakes
  • Difficulty sustaining attention in tasks or play
    activities requires frequent redirection
  • Does not seem to listen when spoken to directly
  • Does not follow through on instructions fails to
    finish task (not oppositional or failure to
    understand
  • Difficulty organizing tasks homework poorly
    organized
  • Dislikes sustained mental effort schoolwork
    homework
  • Loses possessions
  • Easily distracted
  • Forgetful
  • Daydreams
  • Can be very quiet missed

15
Hyperactivity
  • Fidgets squirms
  • Leaves seat when expected to sit
  • Runs or climbs excessively
  • Difficulty in playing quietly
  • Often "on the go" or acts as if "driven by a
    motor"
  • Often talks excessively
  • Perceived  immature 
  • Accidents/injuries prone

16
Impulsivity
  • blurts out answers before questions completed
  • difficulty waiting turn
  • interrupts or intrudes on others
  • Impatient
  • Rushing into things
  • Risk taking Taking dares

17
DSM IV Criteria
  • A
  • 6 / 9 inattention
  • /or
  • 6 / 9 hyperactivity impulsivity
  • 6 months maladaptive inconsistent with
    development level
  • B symptoms before age of 7
  • C impairment in 2 settings
  • D clinically significant social/academic
  • E not better explained by something else

18
Assessment
  • History parents or caregivers,
  • as well as a classroom teacher or other school
    professional
  • Interview of child
  • Parent and teacher ratings of ADHD-related
    behaviours
  • Investigations - No clinical examination or lab
    tests are accepted as either rule in or rule
    out. Recommend vision hearing tested

19
Assessment
  • RATING SCALES
  • - Not diagnostic screening test
  • - Monitor response to interventions
  • PSYCHOMETRICS
  • - WISC/WIAT
  • - CPT
  • - TEA-Ch
  • Others as indicated - Speech language
  • Occupational therapy
  • Auditory processing

20
Differential Diagnosis
21
Differential Diagnosis
  • Hearing Loss
  • Auditory processing
  • Learning Disability
  • Epilepsy
  • CNS abnormality
  • Metabolic
  • Tourettes syndrome
  • Tics
  • Sleep apnoea
  • Lead poisoning
  • Hyperthyroidism
  • Pin worms
  • Autism

22
Differential Diagnosis
  • Emotional distress
  • PTSD
  • Oppositional Defiant Disorder
  • Conduct Disorder
  • Bipolar Disorder
  • Anxiety Disorder
  • Substance Abuse
  • Depression

23
LD VS. ADHD
  • Lacks early childhood history of hyperactivity
  • ADHD behaviours arise in middle childhood
  • ADHD behaviours appear to be task- or
    subject-specific
  • Not socially aggressive or disruptive
  • Not impulsive or disinhibited

24
ADHD VS. ANXIETY DISORDERS
  • Not overly concerned with competence
  • Not anxious or nervous
  • Exhibit little or no fear
  • Have no difficulty separating from parents
  • Infrequently experience nightmares
  • Inconsistent performance
  • Not concerned with future
  • Are not socially withdrawn
  • May be aggressive
  • May be able to pay attention if work is
    stimulating

25
DEPRESSION VS. ADHD
  • Not usually as active
  • Marked changes in affect/mood
  • Concentration problems have acute onset possibly
    following stress event
  • Changes in eating and sleeping habits
  • Loss of interest or pleasure in most activities

26
ODD/CD VS. ADHD
  • Lacks impulsive, disinhibited behaviour
  • Able to complete tasks requested by others
  • Resists initiating response to demands

27
ODD/CD VS. ADHD
  • Lacks poor sustained attention and marked
    restlessness
  • Often associated with parental child management
    deficits or family dysfunction

28
Child abuse victims are at increased risk of a
variety of child and adolescent psychiatric
diagnoses, including depression, anxiety, conduct
disorders, ODD, ADHD and substance abuse. Kaplan
et al Oct 1999
29
Comorbidity
30
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31
As many as one-third of children diagnosed with
ADHD also have a co-existing condition.
32
Comorbidity
  • NEURO- DEVELOPMENTAL
  • learning disorders
  • language disorders
  • cognitive impairment
  • functionally significant soft neurological
    features

33
Comorbidity
  • EMOTIONAL-BEHAVIORAL
  • lowered self esteem
  • downward cycle
  • school failure
  • substance abuse
  • antisocial behaviour
  • violence

34
Comorbidity
  • Conduct problems (e.g., oppositional behaviour,
    lying, stealing, and fighting)
  • Mood or anxiety problems
  • Academic underachievement
  • Specific learning disabilities
  • Peer relationship problems

35
Impact
36
Impact
  • Emotional
  • Low self esteem
  • Impaired self-regulation
  • Relationship difficulties
  • Cognitive
  • Organizing planning and time management
  • Learning delay
  • Short term memory problems lack of focus
  • Language/speech
  • Physical
  • Fine gross motor skill delay
  • Behaviour
  • Impaired self-regulation

37
Impact
  • Pervasiveness of symptoms
  • Persistence of symptoms
  • Associated problems
  • Aggression
  • Psychosocial dysfunction peers, family
  • Poor academic achievement
  • Drug or alcohol use
  • Criminal activity

38
Impact
  • Good family support
  • Higher intelligence
  • Good peer relationships
  • Positive temperament, nonaggressive
  • Emotional health, positive self-esteem
  • Socio-economic factors
  • Diminution or resolution of symptoms

39
Impact
  • 32-40 of students with ADHD drop out of school
  • Only 5-10 will complete college
  • 50-70 have few or no friends
  • 70-80 will under-perform at work
  • 40-50 will engage in antisocial activities
  • More likely to experience teen pregnancy
    sexually transmitted diseases
  • Have more accidents speed excessively
  • Experience depression personality disorders

  • (Barkley,
    2002)

40
School difficulties ADHD
  • High rates of disruptive behaviour
  • Low rates of engagement with academic instruction
    and materials
  • Inconsistent completion and accuracy on
    schoolwork
  • Poor performance on homework, tests, long-term
    assignments
  • Difficulties getting along with peers teachers

41
Life Impairments
  • Childhood
  • Academic and social issues
  • Adolescence
  • Substance abuse, driving accidents
  • Teen pregnancies, dont finish school
  • Young Adults
  • Poor job stability, disrupted marriages
  • Financial difficulties, impulsive crimes

42
Management
43
Psychological Psychiatric
Educational
Behavioural parent training programmes
Substance abuse
Multidisciplinary Management of ADHD
Other individually determined strategies
Coaching
Medical
Dietary
44
Management
  • Psychoeducational
  • Family School
  • Environmental
  • dietary modifications
  • parenting
  • Academic skills training
  • Psychological
  • Cognitive Behavioural
  • Medication

45
Non-Pharmacological Management
  • Family Therapy may be required for reasons such
    as difficulty raising managing a child with
    ADHD and new roles for individuals within the
    family.
  • ADHD in parents may impact success of parent
    training and family therapy

46
Non-Pharmacological Management
  • Diet
  • Elimination diets difficult
  • Omega 3 at least 1000mg/day for a month
  • Academic skills training focus on following
    directions, becoming organized, using time
    effectively, checking work, taking notes

47
Non-Pharmacological Management
  • Behavioural therapy
  • - Does not reduce symptoms
  • May improve social skills and compliance
  • Does not lead to maintenance of gains or
    improvement over time after the therapy is
    completed
  • Social skills group
  • Uses modelling, practice, feedback and contingent
    reinforcement to address the social deficits
    common in children with ADHD
  • Useful for the secondary effects of ADHD, such as
    low self-esteem, but not helpful for core
    symptoms of ADHD

48
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51
MEDICATIONS FOR ADHD
  • Stimulant Medications
  • Methylphenidate (Ritalin, Ritalin LA, Concerta)
  • Dexamphetamine
  • Non-stimulant
  • Atomoxetine (Strattera)
  • Other
  • Clonidine (Catapres)
  • Risperidone (Risperdal)

52
MEDICATIONS FOR ADHD
  • Tricyclic Antidepressants
  • Desipramine Imipramine (Tofranil)
  • Other Antidepressants
  • Bupropion (Zyban) Fluoxetine (Prozac)

53
Stimulants
  • Used to treat ADHD since 1960s
  • 200 placebo controlled studies over 40 years
  • Best studied and most frequently prescribed
  • Precise mechanism of action not known
  • Blockade of pre-synaptic dopamine transporter
  • Beneficial effects seen almost immediately

54
Stimulants
  • Methylphenidate
  • Ritalin 10mg (3-4 hours)
  • Ritalin LA 20/30/40 mg (6-8 hours)
  • Concerta 18/36/54 mg(10-12 hours)
  • Amphetamine
  • Dexamphetamine 10 mg (3-4 hours)

55
Stimulants Specific Effects
  • Improved sustained attention
  • Reduced distractibility
  • Improved short-term memory
  • Reduced impulsivity
  • Reduced motor activity
  • Decreased excessive talking
  • Reduced bossiness and aggression with peers

56
Stimulants Specific Effects
  • Increased amount accuracy of academic work
    completed
  • Decreased disruptive behaviour
  • Improved handwriting and fine motor control
  • Reduced off-task behaviour in classroom
  • Improved ability to work and play independently
    as many as 75 of kids on these medications show
    improvement
  • also seems to cause improvement in kids without
    ADHD in terms of attention and classroom
    behaviour

57
Stimulants
  • Not the only treatment needed, but effective in
    75-90 of ADHD cases (7 through adult years).
  • Side effects few, rarely serious, usually
    manageable.
  • Response to stimulants is NOT diagnostic of ADHD

58
Stimulants
  • Effective during school and homework-time
  • Out of the system by bedtime
  • May use Monday to Friday or 7 days /week
  • Weekend use if significant behavioural
    comorbidity or needed for weekend activity
  • Theoretical could worsen epilepsy
  • Not addictive
  • Use does not predispose to subsequent substance
    abuse protective

59
SIDE EFFECTS OF STIMULANTS
  • Insomnia
  • Decreased Appetite (in 50-60) gtWeight Loss
  • 1-2 cm shorter by end of growth
  • Headaches
  • Stomach aches (20-40)
  • Mood lability/dysphoria
  • Prone to Crying (10) sensitive

60
SIDE EFFECTS OF STIMULANTS
  • Nervous Mannerisms (10)
  • Tics (lt5) and Tourettes (Very Rare) - possible
    exacerbation or uncovering of tics
  • Over focused behaviour Cognitive toxicity
  • (Mild) Increases in Heart Rate and Blood Pressure
  • - NO INCREASE IN SUDDEN DEATH

61
Atomoxetine (Strattera)
  • Potent pre-synaptic, noradrenergic transport
    blocker with low affinity for other
    neurotransmitters
  • Structurally similar to Fluoxetine
  • Metabolized by CYP 2D6 system
  • Half-life 4-5 hours
  • Optimal effects seen at 2 weeks

62
Atomoxetine (Strattera)
  • May be given as single daily dose or bd
  • Dispensed in a capsule that cannot be opened
  • Superior to placebo, but no good data comparing
    efficacy to stimulants yet exists

63
Atomoxetine - Indications
  • Severe side effects to Methylphenidate/Dexamphetam
    ine weight loss insomnia
  • If comorbidity anxiety mood disorders tics
    substance abuse

64
Atomoxetine (Strattera)
  • Adverse effects 5
  • Sedation
  • Nausea and vomiting
  • Decreased appetite
  • Modest increase in pulse and blood pressure
  • Irritability, mood swings
  • Fatigue
  • Urinary hesitancy/prostatism (3)
  • Suicidal ideation

65
Atomoxetine (Strattera)
  • Suicidal Ideation black box warning
  • 2200 in study 1300 on Strattera
  • 5 reported suicidal thoughts
  • No deaths

66
Treatment Implications
  • More formulations now exist, use of which
    involves the art of medicine.
  • Individualize medication for target symptoms,
    target times
  • Stimulants outperform non-drug interventions but
    combination (drug non-drug therapy) is best and
    permits lower drug doses.

67
Hyperactivity and impulsivity are among the most
important personality or individual difference
factors that predict later delinquency. Farringto
n 1996
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69
Disruptive Behaviour Disorders
  • OPPOSITIONAL DEFIANT DISORDER
  • Characterized by repeated arguments with adults,
    loss of temper, anger, and resentment
  • Children with this disorder ignore adult requests
    and rules, try to annoy people, and blame others
    for their mistakes and problems
  • Between 2 and 16 of children will display this
    pattern

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Disruptive Behaviour Disorders
  • CONDUCT DISORDER violate rights of others
  • Aggression to people / animals
  • Conduct causing property loss or
  • damage
  • Deceitfulness or theft
  • Serious rule violation

72
Disruptive Behaviour Disorders
  • Cases of conduct disorder have been linked to
    genetic and biological factors, drug abuse,
    poverty, traumatic events, and exposure to
    violent peers or community violence
  • They have most often been tied to troubled
    parent-child relationships, inadequate parenting,
    family conflict, marital conflict, and family
    hostility

73
Disruptive Behaviour Disorders
  • Because disruptive behaviour patterns become more
    locked in with age, treatments for conduct
    disorder are generally most effective with
    children younger than 13
  • Given the importance of family factors in this
    disorder, therapists often use family
    interventions

74
Disruptive Behaviour Disorders
  • Sociocultural approaches such as residential
    treatment programs have helped some children
  • Individual approaches are sometimes effective as
    well, particularly those that teach the child how
    to cope with anger
  • Recently, the use of drug therapy has been tried
  • Institutionalization in juvenile training centres
    has not met with much success and may, in fact,
    increase delinquent behaviour

75
Disruptive Behaviour Disorders
  • It may be that the greatest hope for reducing the
    problem of conduct disorder lies in early
    intervention programs that begin in early
    childhood.
  • These programs try to change unfavourable social
    conditions before a conduct disorder is able to
    develop.

76
The latest analyses from the Dunedin longitudinal
study show hyperactivity in combination with CD
or CD symptoms is clearly the most important risk
factor for becoming a serious persistent offender
in adulthood. Prof T Moffitt, Maudsley Hospital
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