Download Attention Deficit Hyperactivity , Oppositional Defiant , Conduct

ADHD/ODD/CD
Back to Basics
April 24, 2008
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


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)

Dextroamphetamine
– Dexedrine (regular, slow release)

Adderrall XR
– Mixed amphetamine salts
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
– Fewer than half show total normalization
Others
Buproprion (Wellbutrin)
 Atomoxetine (Strattera)

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

8 criteria
–
–
–
–
–
–
–
–
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!)
• 2 - 16 %

more common in males
• 2:1 or 3:1 males:females

peak age of onset
• 6.5 years
• cases rarely onset after age 10
ODD -- Etiology
Etiology is “multifactorial”
 Combination of genetic and
environmental factors
 Family history of disruptive behavior
disorders, mood disorders, ASPD or
substance abuse

– Increased rates of ODD with maternal
depression
ODD -- Etiology
Parenting style (permissive, inconsistent
discipline, unavailable)
 Harsh inconsistent neglectful child
rearing practices
 Multiple successive caregivers
 Family and marital discord

ODD -- Management
Few controlled studies
 Variety of options

– behavior therapy
– family therapy
– parent management training

Treat comorbidities (i.e.. 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

– 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

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

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
CD -- Subtypes

Adolescent-Onset (cont’d)
– less frequently see ODD, hyperactivity and
school failure
– more likely to be related to peer activities
– limited to adolescence -- rarely continues
into adulthood
– seldom see onset after 16 years of age
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

Factors for Poor Prognosis

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Parental rejection and neglect
Difficult infant temperament
Inconsistent child-rearing practices with harsh
discipline
Physical or sexual abuse
Lack of supervision
Early institutional living
Frequent changes of caregivers
Large family size
Factors for Poor Prognosis (cont’d)
Childhood-onset CD
 Comorbid ADHD
 High level of aggression
 Low intelligence
 Early court involvement
 Peer rejection
 Substance abuse

CD -- Epidemiology

CD is one of the most frequently diagnosed
conditions in mental health facilities
 prevalence
– 2 to 10 %
– boys 6 to 16%
– girls 2 to 9%

peak age of onset is 9 y.o.
 seldom see onset after 16 y.o.
CD -- Etiology

Multifactorial
 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

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

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, clonidine
• Depression - SSRIs
• Anxiety - SSRIs, Buspirone
– to treat CD alone
• Impulsivity/Aggression - mood stabilizers,
neuroleptics
• Hyperactivity - stimulants, clonidine
Enuresis and Encopresis
Clare Gray MD FRCPC
April 24, 2008
Enuresis and Encopresis

Enuresis
– repeated voiding of urine into bed or
clothes
– frequency of twice a week for 3
consecutive months or impairment in
functioning
– at least 5 years old
– not due to substance or medical condition
Enuresis
Nocturnal only
 Diurnal only
 Nocturnal/Diurnal
 Prevalence

– 7-10% boys, 3% girls
– 4:1 male:female ratio
– approx. 3% of boys and 2% of girls have
problems at age 10
Enuresis
Parents may see a child’s failure to
toilet train as a reflection of their
inadequacy as parents
 symptoms become a closely guarded
secret
 anger, frustration and anxiety can occur
 parents may become harsh and punitive

Enuresis

Physiological causes
– Urologic conditions
• infection, obstruction
– Anatomic abnormalities
• congenital anomalies, weak bladder
– Neurologic disorders
• seizures, MR, spinal cord disease
– Metabolic disorders
• diabetes
Enuresis

Functional enuresis
– stress, trauma, psychological crisis
– 50% have comorbid emotional and
behavioural symptoms
– revenge, regression, lack of training

Primary enuresis vs Secondary
enuresis
Enuresis

Treatment
– wait for spontaneous resolution
• 15% per year
– Behavioural treatment
• bladder training exercises, alarms
• restricting nighttime fluid intake, awakenings for
toilet use, star charting
– Medications
• Imipramine (“gold standard”), DDAVP
Encopresis
Repeated passage of feces into
inappropriate places
 one event a month for 3 months
 chronological age of at least 4 years
 not due to substance or medical
condition except through a mechanism
involving constipation

Encopresis
Embarrassing and stigmatizing
condition
 can be either primary or secondary (50
to 60%)
 by age 4, approx 95% of children have
attained bowel continence
 prevalence

– 0.3 to 8% with male:female 4:1
Encopresis
Punitive and coercive toilet training can
create stress and anxiety -- toilet phobia
 other life stressors (birth of sibling)
 early toilet training

Encopresis

Treatment
– Behavioural
• consistent motivation and interest
• praise
• make the bathroom a pleasant and
nonthreatening place
• star charts, rewarding appropriate behaviours
– Medications
• treat constipation -- diet, laxatives etc