Attention deficit hyperactivity disorder (ADHD) and conduct disorder/problems

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Attention deficit hyperactivity disorder (ADHD)
and conduct disorder/problems

• Paul McArdle

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The true measure of a nations standing is how
well it attends to its children their health
and safety, their material security, their
education and socialization, and their sense of
being loved, valued, and included in the families
and societies into which they are born.
Unicef (2007) Child Well-Being in Rich Countries.
Innocenti Research Centre http//www.unicef.ca/por
tal/Secure/Community/502/WCM/PRESS/IRC7/RC7.pdf
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ADHD history

• Moral disorder
• Still 1905
• Minimal brain damage - 1950
• Hyperkinetic syndrome
• Ounsted 1955
• Attention deficit disorder with hyperactivity
• American Psychiatric Association 1981

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Diagnostic symptoms

• Inattention
• Over- or hyper-activity
• impulsivity

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symptoms

• Inattention
• Often fails to give close attention to details,
  makes careless mistakes
• Has difficulty sustaining attention in tasks or
  play
• Does not seem to listen
• Fails to finish tasks
• Often avoids sustained mental effort
• Often forgetful, loses things
• Easily distracted by extraneous stimuli
• Difficulty organising tasks and activities

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Symptoms II

• Hyperactivity/impulsivity
• Often fidgets,
• Leaves seat in classroom
• Often runs about or climbs excessively in
  situations in which it is inappropriate
• Is on the go as if driven by a motor
• Talks excessively

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Symptoms II

• Hyperactivity/impulsivity
• Often fidgets,
• Leaves seat in classroom
• Often runs about or climbs excessively in
  situations in which it is inappropriate
• Is on the go as if driven by a motor
• Talks excessively
• Often blurts out answers
• Has difficulty waiting turn
• Often interrupts or intrudes on others
• Runs out in the street, goes off with strangers
  

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Further criteria

• Early onset before 7 years of age
• Present in more than one setting
• Clear evidence of ...significant impairment in
  social, academic or occupational functioning

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How common is ADHD

• 5 is usual US figure
• More boys than girls
• But less in non-urban and more traditional
  societies.
• Of 2048 adolescents interviewed in Goa, 4 had
  ADHD!
• Pillai et al (2008) Non traditional lifestyles
  and prevalence of mental disorders in adolescents
  in Goa, India. British Journal of Psychiatry
  192(1)45 51.

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Associated features

• Rejection by peers
• Rigid insistence on requests being met and
  bossiness
• Learning and communication disorders
• Tics and Tourette's syndrome
• Increased accidents, including driving accidents
  and fatal crashes
• Mood lability, unhappiness, demoralization
• Antisocial behaviour, substance misuse, crime
• Barkley RA. Cox D. A review of driving risks and
  impairments associated with attention-deficit/hype
  ractivity disorder and the effects of stimulant
  medication on driving performance. Journal of
  Safety Research. 38(1)113-28, 2007.

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Even if IQ is unaffected

• Children with ADHD
• Cannot
• Concentrate, communicate, read and write,
  self-organize, befriend and play to the same
  level as other children of the same age
• Are often judged by parents to be at greater risk
  than others and
• Are typically distressed and unhappy even to the
  degree of 'clinical depression'

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What is thought to be the cause of ADHD

• Nature a neurological or brain condition
• Nurture a product largely of environment (but
  perhaps also affecting brain development)
• Both nature and nurture both brain and
  environment

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Further ADHD comorbidity

• With pragmatic language/ social interaction
  deficits similar to PDD
• Geurts et al (2004) Can the Childrens
  Communication Checklist differentiate between
  children with autism, ADHD and normal controls?
  JCPP (45) 1437-1453
• Bishop Baird (2002) Parent and teacher report
  of pragmatic aspects of communication. Use of the
  CCC in a clinical setting. Developmental Medicine
  and Child Neurology 43809-818
• Gilmour J. et al (2004) Social communication
  deficits in conduct disorder a clinical and
  community survey. JCPP 45(5)967-78.

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A neurological/brain condition

• Executive function deficit, deficit of frontal
  cortical functioning
• 'goal directed behaviour'
• Barkley et al (1997) ADHD and the Nature of Self
  Control New York Guilford Press
• Working memory deficits
• Rapport MD. et al (2008) Working memory deficits
  in boys with attention-deficit/hyperactivity
  disorder (ADHD) the contribution of central
  executive and subsystem processes. Journal of
  Abnormal Child Psychology. 36(6)825-37.

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Trends CD and comorbidity
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Increased disturbance parental report
Collishaw et al (2004) JCPP 45 1350-1362
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Increased disturbance self-report
West Sweeting 2003 JCPP 44399-411
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Trends GHQ scores west of scotland
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Mortality 15-19 year olds
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ADHD and CD

• 'ADHDCD is a quantitative variant of
  ADHD-related behaviours
• Thapar 2001
• Heritability of antisocial behaviour is mediated
  by a callous unemotional trait (Viding et al
  2005)
• Also
• Gene environment correlations gene-environment
  interactionsGenetic influences are strong and
  pervasive but rarely determinative
• Rutter 2002

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Shaw et al 2008 Proceedings of the National
Association of Science
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Nature

• Brain
• injury trauma, anoxia or chemical
• Development affected by genetic factors
• E.g. Martin et al (2002) Observer effects and
  heritability of childhood ADHD symptoms British
  Journal of Psychiatry 180260-265

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Nurture

• Extreme early deprivation
• 'neurodevelopmental programming'
• Stevens et al (2008) inattention/overactivity
  following severe early institutional deprivation
  presentation in early adolescence. Journal of
  Abnormal Child Psychology 36(3)285-293.

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Nurture

• Extreme early deprivation
• 'neurodevelopmental programming'
• Stevens et al (2008) inattention/overactivity
  following severe early institutional deprivation
  presentation in early adolescence. Journal of
  Abnormal Child Psychology 36(3)285-293.
• Subtle deprivation

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Subtle deprivation

• A major study by Play England, part of the
  National Children's Bureau, found that 51 of
  children had been stopped from climbing trees,
  21 from playing conkers and 17 from playing
  games of tag and chase... 'Children are not
  allowed the freedoms that were taken for granted
  when we were children'
• Observer Aug 3rd 2008

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Subtle deprivation

• 'In the West, children are not only socialized
  into a system that promotes individualism,
  competitiveness, and inequality and rejects forms
  of authority but also have to live in the
  unstable family structures such an ideology
  produces (including) ..ambivalence towards
  children'
• Timimi S (2005) the effect of globalization on
  children's mental health BMJ 33137-39

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Subtle deprivation

• 'In the West, children are not only socialized
  into a system that promotes individualism,
  competitiveness, and inequality and rejects forms
  of authority but also have to live in the
  unstable family structures such an ideology
  produces (including) ..ambivalence towards
  children'
• Timimi S (2005) the effect of globalization on
  children's mental health BMJ 33137-39
• Highest rates of disorder among those with
  non-traditional life-styles
• Pillai et al 2008

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Later perpetuating or aggravating factors
mechanism

• social and executive function demands of late
  adolescence overload the late developing
  prefrontal cortex, giving rise to prefrontal
  dysfunction and a lack of inhibitory control over
  antisocial, violent behavior that peaks at this
  age
• Raine (2002) The role of prefrontal deficits, low
  autonomic arousal, and early health factors in
  the development of antisocial and aggressive
  behavior in children JCPP43410434

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ADHD and creativity

• His most extraordinary quality was his titanic
  energy. He could not sit still or stay long in
  the same place. He walked so quickly that those
  in his company had to trot to keep up with him.
  When forced to do paperwork, he paced around a
  stand up desk. Seated at a banquet, he would eat
  for a few minutes, then spring up to see what was
  happening in the next room or to take a walk
  outdoors When he had been in one place for a
  while, he wanted to leave The most accurate
  image is of a man who throughout his life was
  perpetually restless, perpetually in movement.
  From Peter the Great by Robert K Massie.

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ADHD and creativity

• His most extraordinary quality was his titanic
  energy. He could not sit still or stay long in
  the same place. He walked so quickly that those
  in his company had to trot to keep up with him.
  When forced to do paperwork, he paced around a
  stand up desk. Seated at a banquet, he would eat
  for a few minutes, then spring up to see what was
  happening in the next room or to take a walk
  outdoors When he had been in one place for a
  while, he wanted to leave The most accurate
  image is of a man who throughout his life was
  perpetually restless, perpetually in movement.
  From Peter the Great by Robert K Massie.

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treatment

• Structure and support in school
• Opportunities for active play
• Mentors
• Parent training
• Supportive medication