Download Mood & Disruptive Behavior Disorders in Children & Adolescents

Mood & Disruptive Behavior
Disorders in Children & Adolescents
Dr. Bruce Michael Cappo
Clinical Associates, P.A.
Overview
Foundation for Diagnosis
Diagnostic Issues for children &
adolescents
Similarities / differences
Treatment Strategies
Diagnoses
Depression
Bipolar Disorder
Attention Deficit Hyperactivity Disorder
Conduct Disorders
Diagnoses
Oppositional Defiant Disorder
Disruptive Behavior Disorder
Adjustment Disorder with Disturbance of
Conduct
Child or Adolescent Antisocial Behavior
Pervasive Developmental Disorders
A Little History ...
Diagnostic & Statistical Manual of Mental
Disorders (1952)
DSM - II (1975)
DSM - III (1980)
DSM - IIIR (1987)
DSM - IV (1994)
DSM - IV TR 2000 (2000)
Defining Mental Disorder
Clinically significant behavioral or
psychological syndrome or pattern that
occurs in an individual and that is associated
with present distress or disability or with a
significantly increased risk of suffering
death, pain, disability or an important loss of
freedom.
Clinical Judgement
Should NOT be employed mechanically
by untrained individuals
Guidelines to facilitate informed clinical
judgement
NOT to be used in a cookbook fashion
Axis I
Clinical Disorders
Other conditions that may be a
focus of clinical attention
Axis II
Personality Disorders
Mental Retardation
Axis III
General Medical Conditions
Axis IV
Psychosocial & Environmental
Problems
Axis V
Global Assessment of Functioning
Organization
16 Major Diagnostic Classes
Other conditions that may be a focus
Focus here is on a select few of the
disorders of childhood
Disorders of Infancy, Childhood &
Adolescence...
Mental Retardation
Learning Disorders
Motor Skills Disorders
Communication Disorders
Pervasive Developmental Disorders
Attention-Deficit & Disruptive Behaviors
Disorders of Infancy, Childhood & Adolescence
Feeding & Eating Disorders
Tic Disorders
Elimination Disorders
Other Disorders of Infancy & Childhood
Additional Classifications...
Eating Disorders
Sleep Disorders
Impulse Control Disorders
Adjustment Disorders
Personality Disorders
Other conditions that are a focus of clinical attention
Trivia Snapshot
A YoYo can achieve speeds up to
11,000 rpm
Depression
5 or more during a 2 week period which
represents a change in function
depressed mood
irritable mood in children & adolescents
markedly diminished interest in pleasure
significant weight change (5%)
Depression
insomnia or hypersomnia
psychomotor agitation or retardation nearly daily
fatigue or loss of energy nearly daily
feelings of worthlessness or guilt
diminished ability to concentrate
recurrent thoughts of death
not due to substance, bereavement or medical
condition
Age & Gender factors
twice as common in females than males
for adults & adolescents
prepubertal males / females equally
affected
Lifetime Risk Factor
10-25% for women
5-12% for men
Prevalence rates at a given time in
community
5-9% of women
2-3% of men
Risk Factors
Genetic predisposition (especially
maternal)
Avg age of onset is mid 20s
Onset age decreasing
Prepubertal onset may increase risk of
bipolar
Suicide Risk
15% of persons with MDD die by
suicide
Older adult up to 4x that risk
Take statements of self harm very
seriously in children
“Connectedness”
Connected to family & peers
Too much AND too little involvement is
bad
Teach moderation and balance in life
Treatment
Cognitive Behavioral Therapy (CBT)
Pharmacological interventions
Play Therapy in younger kids
Family therapy / Involvement
CBT
Re-interpret situations and responses
Research supports effectiveness over 20 week
period
Faster, not necessarily better when combined
with Medication
Feeling Good by David Burns, MD
Medication
Not always necessary and not a first option in most
cases
SSRIs - Serotonin reuptake inhibitors (zoloft, paxil,
prozac, etc)
2-3 weeks before improvement, optimal at 4 weeks,
change at 5 weeks without improvement
Other classes: tricyclics, MAOIs
Medication
Minimal side effects with SSRIs
33% of adolescents take meds as prescribed
“If I take meds then there must be something
wrong with me...I don’t want anything to be
wrong so I won’t take meds”
Play Therapy
Often indirect
Puppets, games, role playing
Family Therapy
Systems Approach
Clarify roles in family
Identify and change dysfunction
Bipolar
I
One or more manic or mixed episodes
often one or more depressive episodes
II
recurrent major depressive episodes with
hypomanic episodes
Manic Episodes
Elevated, expansive or irritable mood
inflated self esteem or grandiosity
decreased need for sleep
more talkative, pressured speech
flight of ideas
Manic Episodes
distractibility
increased goal directed activity
excessive involvement in pleasurable
activities
despite adverse consequences
marked impairment
Hypomanic episode
shorter, 4 versus 7 days minimum
not as severe - need not cause
marked impairment
Treatment
Pharmacological
Educate on chronic nature of disorder
Coping strategy development
Recognize early warning signs of mood
shift
Family education
Medication
Lithium carbonate, Depakote, Neurontin,
Topamax, Tegretol, SSRIs
Compliance is a chronic problem
Very likely to discontinue meds and have
problems
Therapy to promote compliance and
understanding
Trivia Snapshot
It is actually the tomato sauce
that burns your mouth when
pizza is too hot - NOT the cheese

Attention Deficit Hyperactivity Disorder
ADHD
ADD
Attention Deficit Disorder with/without
Hyperactivity
Name has changed in DSM through the years
Prevalence
Estimates range from 2% - 5% of girls and
from 5% - 7% of boys
Symptoms present & diagnosable by age 7
ADD Symptoms decrease with age
Comorbidity increases with age
DSM IV Criteria (summarized)
Inattention, impulsivity or hyperactivity
Onset before age 7
Symptoms seen in at least 2 situations (home,
school, etc.)
Significant impairment in functioning
Diagnostic Criteria (type)
Attention Deficit Disorder
Inattentive Type
Impulsive Type
Hyperactive Type
Combined Type
Attention Deficit Disorder
Types
Inattentive
25 - 30%
Hyperactive
Impulsive
Combined
70 - 75%
Inattention
Difficulty sustaining attention
Does not seem to listen
Makes careless mistakes
Fails to complete tasks without being
oppositional
Inattention
Difficulty organizing activities
Easily Bored
Loses things
Forgetful
Easily distracted
Hyperactivity
Runs about inappropriately
Has difficulty staying in seat
Fidgets or squirms
Does not play alone quietly
“Motor Driven”
Impulsivity
Interrupts others
Blurts out answers in class before called on
Has difficulty awaiting his/her turn
Prevalence
2-5%
Higher for boys than girls
Symptoms present & diagnosable by age 6
ADD
Symptoms
decrease
with age
Comorbidity
increases
with age
Comorbidity Factors
50% - 80% have some comorbid condition
Oppositional Defiant Disorder
Conduct Disorder
Impaired Academic Functioning
Mood Disorders
Tic Disorders
Oppositional Defiant Disorder
40% of children
65% of adolescents
Conduct Disorder
21% - 45% of children
44% - 50% of adolescents
Impaired Academic Functioning
40% in special education classes
19% - 26% with at least one
learning disorder
Mood Disorders
15% - 20% with Depression
20% - 25% with Anxiety
Tic Disorders
10% with Tourette’s Syndrome
Assessment
Detailed history
Objective assessment devices
Norm-based symptom scales for parents
Norm-based symptom scales for teachers
Clinical impressions / interview
Detailed History
Early growth & development
Social
Behavior
Academic functioning
Family functioning
Objective Assessment Devices
Continuous Performance Tests (CPT)
Intelligence Tests
Achievement Tests
Norm-based symptom scales for parents & teachers
Conners
Auffenbach
Brown
Yale
& Many Others
Treatment
Parent Training
Social Skills Training
Educational Consultation
Psychopharmacologic Treatment
Non-Medication Interventions
Control Setting Variables
Control Task Variables
Token System
Self-Monitoring
Contracting
Pharmacologic Interventions
Stimulants
SSRIs
Antihypertensives
Anticonvulsants
Commonly Prescribed Stimulants
Ritalin (methylphenidate)
Dexedrine (dextroamphetamine)
Adderall (amphetamine mixed salts)
Concerta (methylphenidate)
Metadate (methylphenidate)
Out of favor - Cylert (pemoline)
There is poor correspondence between clinical effects &
blood levels
Test / Re-Test Paradigm better than mg/kg body weight
dosing
Ritalin (methylphenidate)
Around over 50 years
5 mg to 60 mg per day in divided doses
Mixed experience with sustained release but may
work well in combination with non-SR
Onset 15-30 minutes; Peak 90 minutes; lasts 4-6
hours
New product on the way with 12 hour dosing
Adderall
6-8 hours
Good choice for younger kids without
homework
Most get by with once a day dosing
Concerta
18 mg & 36 mg
12 hours
Once daily dosing
Must take capsule whole
more expensive
Metadate
10 hours
30% fast actng
70% slow acting
Less expensive
Can be sprinkled on food
Other Classes of Medications Used
Antidepressants
Tofranil (imipramine)
Wellbutrin (buproprion)
Prozac (fluoxetine)
Zoloft
Often in combination with Ritalin
Other Classes of Medications Used
Blood Pressure Meds
Tenex (guanfacine)
Catapres (clonidine)
Others less used
Buspar (buspirone)
Lithium Carbonate
Treatment using a multi-modal
approach
parent training
behavior management
environment management
classroom interventions
Summary
Assess & diagnose properly
Medication is a primary
intervention
Multi-modal approach is preferred
to meds only
Trivia Snapshot
When you watch a baseball game on TV you
actually hear the crack of the bat sooner than the
fans at the game because of the placement of the
microphone and the speed of sound versus the
speed of the electrical transmissions used for
broadcasting the signal
Conduct Disorders
Repetitive pattern of behavior in which the basic
rights of others or major societal norms/rules are
violated
Clinically significant impairment in social,
academic or occupational functioning
Conduct Disorders
3 or more in past 12 months
aggression to people or animals
destruction of property
deceitfulness or theft
serious violations of rules
Prevalence
Elementary - 2% girls, 7% boys
Middle - 2-10% girls, 3-16% boys
High School - 4-15% boys & girls
Higher in urban than rural
Looking Ahead
50% of those showing Sx in
elementary school continue to do so
during adolescence
40-75% of adolescents continue Sx
as adults
High Risk Signs
ADHD
Early onset before age 10 (most important)
Multiple types of antisocial behaviors
stealing, lying, fighting
High frequency of acting out
Behaviors displayed in multiple settings
school, home, community
Comorbidity
21% Major Depression or Bipolar
Disorder
24% Anxiety Disorder
31% ADHD
Treatment
Behavior Therapy
Cognitive Therapy
Family Therapy
Group Therapy
Psychodynamic or Interpersonal Therapy
Behavior Therapy
Parent training
School based management programs
Token Systems
Reinforce desired behaviors through
multiple settings
Cognitive Therapy
Changing ineffective thought processes
Consider potential and actual
consequences of behavior
Connect choices with outcomes
Consider potential and actual
consequences of behavior
Cognitive Therapy
Connect choices with outcomes
Problem solving techniques
Social Processing Deficits
misinterpret situations
base response on misinterpretations
event - anger - run away
Family Therapy
Changing family communication
processes
Identify and change dysfunctional
systems
Clarify roles
Group Therapy
Facilitate contact with prosocial peers in
structured setting
“old guy in a tie” vs “experts”
Confrontation by peers
Mixed groups with experienced leaders did
best
Psychodynamic / Interpersonal Therapy
Attachment theory
Improve relationship with parent
and others
Less research support
Effectiveness
Decreased Sx shown after 3-4 months of Tx
Some did well at 1 year follow-up
Some do not maintain Tx gains
Lowered recidivism rates 6 - 18 months out
Number of serious criminal offenses stayed the same
These may be more difficult cases
May require higher level of treatment
Oppositional Defiant Disorder
Pattern of negativistic, hostile & deviant
behavior lasting at least 6 months during
which 4 are present often
loses temper
argues with adults
actively defies requests or rules
Oppositional Defiant Disorder
blames others for his misbehaviors
easily annoyed by others
angry & resentful
spiteful & vindictive
Oppositional Defiant Disorder
There is clinically significant impairment in
social, academic or occupational functioning
not specific to a psychotic or mood disorder
does not meet criteria for conduct disorder
Disruptive Behavior Disorder
Ongoing pattern of CD & ODD
behaviors that fail to meet criteria
for full diagnosis
Adjustment Disorder with Disturbance of
Conduct
Can be with Mixed Emotional Features also
Occurs within 3 months of identifiable
stressor
Can include mood swings
Child or Adolescent Antisocial Behavior
Isolated antisocial behaviors not
considered indicative of a mental
disorder
i.e. shoplifting but no other problems
Pervasive Developmental Disorders
Severe & pervasive impairment in several areas
of development
Reciprocal social interactions skills
Communication skills
Stereotyped behaviors, interests, activities
Deviant to developmental level or age
Pervasive Developmental Disorders
Autistic disorder
Rett’s disorder
Childhood disintegrative disorder
Asperger’s disorder
PDD NOS
Autistic Disorder Criteria
Qualitative impairment in social interaction
Marked impairment in nonverbal behaviors
eye contact, facial expressions, gestures
Failure to develop peer relationships
Lack of spontaneously seeking to share
enjoyment
Lack of emotional reciprocity
Autistic Disorder Criteria
Delay / Lack of developed spoken
language
When speech present - not initiate or
sustain conversations
Idiosyncratic language
Lack of varied spontaneous play
Autistic Disorder Criteria
Restricted, stereotyped patterns of
behavior
Inflexible adherence to rituals
Repetitive motor mannerisms
Preoccupation with parts of objects
Rett’s Disorder
Distinctive regression of abilities and
slowed head growth
Only females
Less frequent than Autism
Rett’s Disorder Criteria
Normal prenatal & perinatal
development
Normal development first 5 months
Normal head circumference at birth
Rett’s Disorder Criteria
Decelerated head growth 5 - 48 months
Loss of previously acquired skills
Development of steretyped hand
movements
Loss of social engagemenet
Poor coordination
Asperger’s Disorder
No mental retardation which may be
present in Autistic disorder
Mild level of delay symptoms
Good verbal skills usually
Frequently seen with ADHD &
depressive disorders
Asperger’s Disorder
Increased interest in social relationships
but impaired ability
May duplicate routines or rules without
understanding
Frequent behavior problems in
adolescence
Types of Social Behavior Dysfunction
Key defining feature of autism
Can be classified into three categories:
socially avoidant
socially indifferent
socially awkward.
Socially Avoidant
Avoid virtually all forms of social
interaction
Tantrum and/or 'run away' when someone
tries to interact with him/her
As infants, some are described as 'arching
their back' from a caregiver to avoid contact
Socially Indifferent
Don’t seek social interaction with others (unless
they want something)
Don’t actively avoid social situations
Don’t seem to mind being with people
Don’t mind being by themselves
Common in the majority of autistic individuals
Socially Indifferent
One theory is that autistic individuals do not obtain
'biochemical' pleasure from being with people. Research by
Professor Jaak Panksepp at Bowling Green State University in
Ohio has shown that beta-endorphins, an endogenous
opiate-like substance in the brain, is released in animals
during social behavior. Additionally, there is evidence that the
beta-endorphin levels in autistic individuals is elevated so
they do not need to rely on social interaction for pleasure.
Some research on the drug, naltrexone, which blocks the
action of beta-endorphins, has shown to increase social
Socially Awkward
Try very hard to have friends, but cannot keep them
Common to Asperger Syndrome
Lack reciprocity in their interactions
Conversations often revolve around themselves & are
self-centered
They don’t learn social skills and social taboos by
observing others
Lack common sense when making social decisions
Treatment
Sensory Based
BioMedical
Social
Sensory
If the problem appears to be due to
hypersensitivity to sensory stimuli, sensorybased interventions may be helpful, such as
auditory integration training, sensory integration
& visual training. Another strategy would be to
remove these sensory intrusions from the
person's environment.
Biomedical
Naltrexone is usually not prescribed to
improve social interaction; however,
research studies and parent reports have
indicated improved social skills when given
Vitamin B6 and magnesium, and/or
dimethylglycine (DMG) Research is mixed
on this. Lots of anecdotal stories on internet
Social
A treatment strategy to improve social
behavior is using 'social stories'. This
involves presenting short stories to teach
socially appropriate behaviors. These stories
are used to teach the individual to
understand the behavior of themselves and
others better.
Time For Your Questions