DEVELOPMENTAL DISORDERS

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DEVELOPMENTAL DISORDERS
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OUTLINE

• Attention-Deficit Hyperactive Disorder
• Tourettes Disorder
• Conduct Disorder
• Oppositional Defiant Disorder

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Childhood Disorders

• apparent and diagnosed in childhood
• can persist to adulthood
• some adulthood disorders can also be seen in
  childhood
• ex. anxiety, depression, child-onset
  schizophrenia..

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ATTENTION DEFICIT HYPERACTIVITY DISORDER
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ADHD Symptoms (DSM-IV)

• A. Symptoms of Inattention
• cannot attend to details careless mistakes
• trouble sustaining attention
• does not listen
• does not follow instructions
• difficulty organizing
• avoids, dislikes tasks that require mental effort

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Cont...

• Often loses things necessary for tasks
• distracted by extraneous stimuli
• forgetful of daily activities

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Cont...

• B. Symptoms of Hyperactivity-Impulsivity
• Hyperactivity
• fidgets or squirms
• leaves seat appropriately
• runs about or climbs inappropriately
• difficulty playing quietly or quiet activities
• on the go
• talks incessantly

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Cont...

• Impulsivity
• blurts out answers before questions asked
• has difficulty awaiting turn
• interrupts or intrudes on others

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REQUIREMENTS FOR DIAGNOSIS

• ADHD predominantly inattentive type
• ADHD predominantly hyperactive-impulsive type
• ADHD combined types

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ASSOCIATED CHARACTERISTICS

• Intelligence, learning disabilities, academic
  performance
• Executive Functions
• Social and Conduct Problems
• Accident and Injury
• Adaptive Functioning
• Motivational Aspects

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Cont...

• Two brains systems that work in opposition of
  each other
• 1. Behavioral Inhibition System
• 2. Behavioral Activation System

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Co-occurring Disorders

• Learning disabilities
• Oppositional Defiant Disorder and Conduct
  Disorder
• Anxiety and Mood Disorders

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Epidemiology Etiology

• 3-5 of school population
• decline with age more often in boys
• pregnancy and birth complications
• diet
• environmental lead
• psychosocial factors

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Genetic

• commonly has one or both parents with ADHD
• fathers ADHD, alcoholism, antisocial PD
• mothers alcoholism, hysterical personality
• siblings
• first degree relatives conduct disorder,
  depression, tics, language disorders

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Cont...

• with psychiatric controls
• higher risk of ADHD, antisocial PD, mood
  disorders
• higher risk for anxiety and drug dependence
• cannot be accounted for by gender, generation of
  relative, age of proband, social class, or
  intactness of family

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Cont...

• Relatives with ADHD vs. Relatives withoud ADHD
• oppositional defiant disorder
• conduct disorder
• various sexual behaviors
• depression
• alcohol/drug abuse

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Adoption and Twin Studies

• strong genetic component
• adopted children with a biological parent with
  ADHD
• increase in ADHD, rages, and temper tantrums

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ADHD vs. Tourettes

• 50-80 have ADHD as well as Tourettes
• Tourettes is basically ADHD with tics?
• Tourettes with ADHD more likely to visit doctor
• depression, oppositional defiant disorder,
  alcoholism, drug abuse, sexual,a dn other
  disorders

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General Neuroanatomy

• brain damage
• cerebral volume 5 smaller
• Frontal lobes asymmetry, white matter
• Caudate Nucleus, Putamen, Globus Pallidus
• Cerebellum
• Corpus Callosum

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PET Studies

• Frontal cerebral metabolism blood flow in
  striatum and prefrontal areas
• labelling catecholamine terminals prefrontal
  cortex, striatum, and midbrain regions

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fMRI Studies

• caudate nucleus putamen
• prefrontal cortex
• VTA to PFC reverse effects in striatum
• brake system is localized in right prefrontal
  lobe response inhibition
• bilateral anterior cingulate in normals

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Abnormal functioning of frontal-striatal areas?
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DOPAMINE

• D2 Receptor
• impulsive, compulsive, and addictive behaviors
• D4 Receptor
• high degree of variability
• D3 Receptor
• knockout mice
• D1 Receptor
• addictive behaviors

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NOREPINEPHRINE

• defects in NE metabolism
• noradrenergic agonist
• lower rates of NE excretion depletion
  distractability activity
• Epi is lower
• Prefrontal lobes
• Parietal lobes

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SEROTONIN

• Implicated in the etiology of ADHD, Tourettes,
  and Conduct Disorder
• tryptophan levels
• conflicting reports
• SSRIs in animal models in humans?

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GABA

• since ADHD and TS are disorders of disinhibition
• genetic defects in GABA pathways?
• modulating DA metabolism

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Treatment of ADHD

• Stimulants
• ex. Ritalin (mehtylphenidate)
• Antidepressants
• Anticonvulsants
• Antihypertensives
• Antipsychotics

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Why would stimulants be most effective?
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Stimulants

• 75 respond to this medication
• do not outgrow ADHD medication
• dopamine norepinephrine
• rapid effects, but wear off quickly
• side effects

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.. effects on DA system

• High doses of DOPA vs. low doses of DOPA
• normal release of DA
• 1. At rest steady levels of DA in the synapse
• 2. During nerve impulses pulsatile manner

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Cont...

• DA transporter
• where Ritalin works to increase DA in synapse
• high resting rate created smaller relative
  increase during nerve impulse
• in frontal cortex
• What about striatal system?
• What about adrenergic effects?

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OPPOSITIONAL-DEFIANT CONDUCT DISORDERS
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Aggressive Deliquent Behaviors

• Aggressive
• argues, brags, demands attention, destroys
  things, disobendient, fights, jealous, screams,
  stubborn, temper tantrum, loud, defiant, etc.
• Deliquent behavior
• lack of guilt, lies, runs away from home, sets
  fires, steals, swearing, obsenticity, truancy,
  alcohol, drugs, vandalism, etc.

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ODD Symptoms (DSM-IV)

• Loses temper, argues
• refuses to comply with requests rules
• deliberately annoys others
• transfers blame
• easily annoyed angry resentful
• spiteful vindicative

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CD Symptoms (DSM-IV)

• Aggression toward People and Animal
• bullies, threatens, or intimidates
• intiates fights
• has used a weapon
• physically cruel to animals people
• stolen while confronting a victim
• forced someone into sexual activity

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Cont...

• Destruction of Property
• deliberately engaged in fire setting
• destroyed others property
• Deceitfulness or Theft
• broken into houses, building, or cars
• lies to obtain goods or favours avoids
  obligations
• stolen nontrivial items without confronting a
  victim

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Cont...

• Serious Violations of Rules
• stays out at night despite prohibitions
• run away from home at least twice or one long
  period
• is truant from school

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Patterns of Co-occurrence

• cannot receive both diagnoses
• how related are these disorders?
• changing over time?
• considerable co-occurrence with ADHD
• challenges of parenting ADHD child?
• anxiety depression

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Epidemiology Etiology

• most often referred to clinicians
• prevalence rates CD 2-10 ODD 6-10
• seen more often in males than in females
• aggression as a learned behavior
• parenting styles

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Genetics

• related disorder antisocial PD is genetically
  linked
• adolescent vs. adult behaviors
• often do not persist into adulthood
• certain characteristics inherited that make an
  individual prone to antisocial behavior?

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Treatments

• Pharmacotherapy?
• Multimodal interventions
• age and social context
• 3 psychosocial treatments
• 1. Parent-management training
• 2. Cognitive problem-solving skills training
• 3. Multisystemic therapy

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Cont

• Medication only likely to be considered
• 1. Other treatments have failed
• 2. Main symptom is overt
• 3. Comorbid diagnoses that is likely to respond
  to medication

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Mood Stabilizers Anticonvulsants

• Lithium carbonate
• severe side effects
• Carbamazepine (anticonvulsant)
• Valproate (antiseizure)

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Neuroleptics

• Suppress aggression
• perhaps sedation?
• most commonly prescribed
• antipsychotics typical vs atypical
• side effects?

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Stimulants

• DA agonists have adverse effects on social
  behavior? Dose dependent?
• Linking ADHD and CD

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Other Compounds

• Clonidine
• beta-adrenergic blockers
• antidepressants