Download Back to Basics Child and Other Psychiatry

ADHD/ODD/CD/Tic
Disorders
Back to Basics
March 19, 2012
Clare Gray MD FRCPC
Attention Deficit Hyperactivity
Disorder
3 - 7% school aged children
 male:female 3-6 : 1
 Diagnostic Triad

– Inattentiveness
– Impulsivity
– Hyperactivity
Inattentive Symptoms
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6 or more, for 6 months or more
Fails to give close attention to details or
makes careless mistakes
 Often has difficulty sustaining attention
 Often doesn’t seem to listen
 Often doesn’t follow through on instructions
or fails to finish schoolwork, chores
Inattentive Symptoms
Often has difficulty organizing tasks and
activities
 Often loses things necessary for tasks
and activities
 Often easily distracted by extraneous
stimuli
 Often forgetful in daily activities

Hyperactivity Symptoms
Often fidgets, squirms in seat
 Often leaves seat in classroom
 Often runs about or climbs excessively
 Often has difficulty playing quietly
 “on the go” or often acts as if “driven by
a motor”
 Often talks excessively

Impulsivity Symptoms
Often blurts out answers before
questions have been completed
 Often has difficulty awaiting turn
 Often interrupts or intrudes on others

ADHD
Onset before 7 years old
 impairment in 2 or more settings
 significant impairment in functioning
 symptoms not due to another
psychiatric disorder (PDD,
Schizophrenia, Mood disorder, Anxiety
disorder, Dissociative or PD)

ADHD

Types
– Combined Type
– Predominantly Inattentive Type
– Predominantly Hyperactive/Impulsive Type
– NOS
ADHD
Diagnosis of exclusion
 based on history
 can use Connors Rating Scales
completed by parents and teachers
 importance of multiple sources of
information about the child in different
settings

ADHD

Treatment
– Medication
– Psychosocial treatments
ADHD Treatment

Medications
– Stimulants
– Antidepressants
– Clonidine
– Atypical antipsychotics
Stimulants

Methylphenidate
– Ritalin (regular, slow release)
– OROS Methylphenidate (Concerta)
– Biphentin

Dextroamphetamine
– Dexedrine (regular, slow release)

Adderall XR
– Mixed amphetamine salts

Lisdexamfetamine (Vyvanase)
– Prodrug – consists of dextroamphetamine coupled with the
essential amino acid L-lysine
– converts to dextroamphetamine in the body
Contraindications to Stimulants
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Previous sensitivity to stimulants
Glaucoma
Symptomatic cardiovascular disease
Hyperthyroidism
Hypertension
MAO inhibitor
Use very carefully if history of substance
abuse
Stimulants

Monitor Carefully if:
– Motor tics
– Marked anxiety
– Tourette’s syndrome
– Seizures
– Very young (3-6 year olds)
Stimulants -- Side Effects
Delay of sleep onset
 Reduced appetite
 Weight loss
 Tics
 Stomach ache
 Headache
 Jitteriness

Effectiveness of Stimulants

At least 70% response rate to first
stimulant tried
Others

Buproprion (Wellbutrin)
– Atypical antidepressant
– NE and DA reuptake inhibitor
– Lowers seizure threshold

Atomoxetine (Strattera)
– SNRI
– Takes 1 to 4 weeks for effects
– “24 hour” coverage
ADHD

Psychosocial treatments
– parent training
• psychoeducation, behaviour management,
support
– school interventions
• remediation, behaviour management,
– individual therapy
• anger management, supportive, CBT,
psychoedn
Oppositional Defiant Disorder

Key feature
– pattern of negativistic, hostile and defiant behavior
toward authority figures

DSM IV criteria
– 8 types of behaviour
– require 4 or more of these lasting at least 6
months
– causing clinically significant impairment in
functioning
• Behaviours happen more frequently than would be
typical for the patient’s age and developmental level
DSM IV Criteria
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8 criteria
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often loses temper
often argues with adults
often actively defies adults’ requests or rules
often deliberately annoys people
often blames others for his/her misbehavior
often is easily annoyed by others
often is angry and resentful
often is spiteful or vindictive
ODD -- Diagnosis
Important not to confuse ODD with
normal development
 toddlers and adolescents go through
oppositional phases
 behaviors occur in patient more
frequently than with peers at same
developmental level

ODD - Epidemiology

prevalence rates (lots of different data!)
• 1 - 16 %

more common in males
• 2:1 males:females

onset usually by 8 years of age
Etiology – Biological Factors
Parent with DBD, mood disorder,
substance abuse disorder
 Maternal smoking during pregnancy
 Abnormalities of prefrontal cortex
 Altered 5HT, NA and DA

Etiology – Psychological Factors
Poor relationship with parents (insecure
attachment)
 Neglectful/absent parent
 Difficulty or inability to form social
relationships

Etiology – Social Factors
Poverty
 Chaotic environment (lack of structure)
 Lack of parental supervision
 Lack of positive parental involvement
 Inconsistent discipline
 Abuse/neglect

ODD -- Management
Few controlled studies
 Variety of options

– behavior therapy
– family therapy
– parent management training
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Treat comorbidities (ADHD)
Conduct Disorder
A persistent pattern of behavior in which
the rights of others and/or societal
norms are violated
 DSM IV -- 4 categories of behavior
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– aggression to people and animals
– destruction of property
– deceitfulness or theft
– serious violation of rules
aggression to people and animals
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Often bullies, threatens or intimidates others
Often initiates physical fights
Has used a weapon that can cause serious
physical harm to others
Has been physically cruel to people
Has been physically cruel to animals
Has stolen while confronting a victim
Has forced someone into sexual activity
destruction of property
Has deliberately engaged in fire setting
with the intention of causing serious
damage
 Has deliberately destroyed others’
property

deceitfulness or theft
Has broken into someone else’s house,
building or car
 Often lies to obtain goods or favors or to
avoid obligations
 Has stolen items of nontrivial value
without confronting a victim

serious violation of rules

Often stays out at night despite parental
prohibitions, beginning before age 13 years
 Has run away from home overnight at least
twice while living in parental or parental
surrogate home (or once without returning for
a lengthy period)
 Is often truant from school, beginning before
13 years
CD -- Diagnosis

need to have 3 or more of these behaviors in
the previous 12 months, with at least 1 criteria
present in past 6 months
 impairment in functioning
 If >18 y.o., criteria not met for ASPD
 Subtypes
– early (childhood) onset
– late (adolescent) onset
CD -- Subtypes
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Childhood-Onset (onset of at least one
criterion prior to age 10 years)
– usually more aggressive, usually male
– poor peer relationships
– these are the ones that are more likely to
go on to Antisocial PD
CD -- Subtypes
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Adolescent-Onset (absence of any
criteria prior to age 10 years)
– tends to be less severe
– less aggressive
– better peer relationships
– more often female
– lower male:female ratio
Associated Features
Little empathy
 Little concern for feelings and well being
of others
 Misperceive the intentions of others as
hostile and threatening
 Callous
 Lack remorse or guilt (other than as a
learned response to avoid punishment

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Only 3 risk factors have been shown to
be “causal”
– harsh, inconsistent parenting
– poor academic performance
– exposure to parental discord
CD -- Etiology

Combination of genetic and environmental
factors
 Risk for CD is increased in children with
– a biological or adoptive parent with ASPD
– a sibling with CD

Environmental factors
– poor family functioning (poor parenting, marital
discord, child abuse)
– family history of substance abuse,mood d/o,
psychotic d/o, ADHD, LD, CD and Antisocial PD
Antisocial Personality Disorder

Pervasive pattern of disregard for and
violation of the rights of others occurring
since age 15 years
 3 or more of:
– Failure to conform to social norms with respect to
lawful behaviours – repeatedly performing acts
that are grounds for arrest
– Deceitfulness, repeated lying, use of aliases or
conning others for personal profit or pleasure
– Impulsivity or failure to plan ahead
Antisocial Personality Disorder
– Irritability and aggressiveness, repeated physical
fights or assaults
– Reckless disregard for safety of self or others
– Consistent irresponsibility – repeated failure to
sustain consistent work behaviour or honour
financial obligations
– Lack of remorse – being indifferent to or
rationalizing having hurt, mistreated or stolen from
another
Antisocial Personality Disorder
At least 18 years of age
 Evidence of CD, with onset before age
15 years
 Not due to Schizophrenia or Mania
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CD -- Course

< 50% of CD have severe and
persistent antisocial problems as adults
CD – Protective Factors
easy temperament
 above average intelligence
 competence at a skill
 a good relationship with at least 2
caregiving adult
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CD -- Management

4 treatments that show the most
promise for treating CD based on good
studies that have been replicated
– cognitive problem solving skills training
– parent management training
– family therapy
– multisystemic therapy
CD -- Management

Pharmacological
– to treat comorbid conditions
• ADHD – stimulants
• Depression - SSRIs
• Anxiety - SSRIs
– to treat CD alone
• Impulsivity/Aggression - mood stabilizers,
neuroleptics
Tics
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Part of the body moves repeatedly, quickly,
suddenly and uncontrollably
Can occur in any body part, such as the face,
shoulders, hands or legs
Sounds that are made involuntarily (such as
throat clearing) are called vocal tics
Most tics are mild and hardly noticeable
In some cases they are frequent and severe,
and can affect many areas of a child's life
Tics
5 to 24% of all school age children have
had tics at some stage during this
period
 Prevalence of Tourette’s syndrome is 1
to 10 per 10,000

– 3 to 9 x’s more common in males
– Mean age of onset 6 to 7 years of age

Tics appear to get worse with emotional
stress and are absent while sleeping.
Clinical Course – Tourette’s
Transient Tic Disorder
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The patient has vocal or motor tics,or both. They can be
single or multiple.
For at least 4 weeks but no longer than 12 consecutive
months, these tics have occurred many times each day, nearly
every day.
These symptoms cause marked distress or materially impair
work, social or personal functioning.
They begin before age 18.
The symptoms are not directly caused by a general medical
condition (such as Huntington's disease or a postviral
encephalitis) or to substance use (such as a CNS stimulant).
The patient has never fulfilled criteria for Tourette’s Disorder or
Chronic Motor or Vocal Tic Disorder
Chronic Tic Disorder
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Single or multiple motor or vocal tics, but not both, have been
present at some time during the illness.
The tics occur many times a day nearly every day or
intermittently throughout a period of more than 1 year, and
during this period there was never a tic-free period of more than
3 consecutive months.
The disturbance causes marked distress or significant
impairment in social, occupational, or other important areas of
functioning.
The onset is before age 18 years.
The disturbance is not due to the direct physiological effects of a
substance or a general medical condition
Criteria have never been met for Tourette’s Disorder
Tourette’s Disorder
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Both multiple motor and one or more vocal tics
have been present at some time during the illness,
although not necessarily concurrently
The tics occur many times a day (usually in bouts)
nearly every day or intermittently throughout a period
of more than 1 year, and during this period there
was never a tic-free period of more than 3
consecutive months.
The onset is before age 18 years.
The disturbance is not due to the direct physiological
effects of a substance or a general medical condition.
Comorbidity
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ADHD
– 50% of patients with TS have ADHD
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Learning Disabilities
– 25 to 30% of patients with TS have LDs
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OCD
– 25 to 40% of patients with TS have OCD
Treatment

Depends on
– severity,
– the distress it causes to the patient
– the effects the tics have on school or job
performance.
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Medication and psychotherapy are used
only when there is substantial
interference with ordinary activities
Treatment

Neuroleptics
– Pimozide
– Risperidone
– Haloperidol
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Other options
– Clonidine
Treatment

Habit-reversal training (HRT)
– Awareness training
• accentuates sensitivity to tic sensations
– Competing response training
• taught a specific response pattern that would
be incompatible with the tic
• replaces the tic behaviour with a more
appropriate competing response
Antares is the 15th brightest start in the
sky
 It is more than 1000 light years away
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So just try to keep everything in
perspective!!
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Good Luck with the Exam!
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Any questions – [email protected]