Disruptive Behaviour Disorders

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Disruptive Behaviour Disorders

• Donna Dowling
• Child Adolescent Psychiatrist
• Townsville CAYAS

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• ADHD ( ADD)
• Oppositional Defiant Disorder
• Conduct Disorder

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Epidemiology
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Epidemiology

• Around 3-5 of schoolchildren display ADHD, as
  many as 90 of them boys
• Worldwide studies consistent not just western
  disease
• Many children show a lessening of symptoms as
  they move into adolescence
• At least half continue to have problems
• One-third of those affected have symptoms into
  adulthood

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Aetiology
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Aetiology

• Heritability is the strongest factor in
  development of ADHD
• Risk factors account for only a small portion of
  variance
• Pregnancy variables young maternal age, maternal
  use of tobacco and alcohol, toxaemia,
  post-maturity and extended labour
• Medical factors fragile X syndrome, G6PD
  deficiency, phenylketonuria, brain trauma, lead
  poisoning, malnutrition

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Main Neurotransmitters in ADHD

• Dopamine
• Noradrenaline
• To regulate the inhibitory influences in the
  frontal-cortical processing of information

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Dopamine

• - enhances signals - improves
• . attention, . focus vigilance, .
  acquisition, . on-task behaviour and cognition

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Noradrenaline

• dampen  noise 
• decrease distractibility and shifting
• improve executive operations
• increase behavioural, cognitive, motoric
  inhibition

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Aetiology

• ADHD symptoms and a diagnosis of ADHD may
  themselves create interpersonal problems and
  produce additional symptoms in the child
• Some children sensitive to colourings/preservative
  s not sugar per se

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Diagnosing ADHD
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Inattention symptoms

• Fails to give close attention careless mistakes
• Difficulty sustaining attention in tasks or play
  activities requires frequent redirection
• Does not seem to listen when spoken to directly
• Does not follow through on instructions fails to
  finish task (not oppositional or failure to
  understand
• Difficulty organizing tasks homework poorly
  organized
• Dislikes sustained mental effort schoolwork
  homework
• Loses possessions
• Easily distracted
• Forgetful
• Daydreams
• Can be very quiet missed

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Hyperactivity

• Fidgets squirms
• Leaves seat when expected to sit
• Runs or climbs excessively
• Difficulty in playing quietly
• Often "on the go" or acts as if "driven by a
  motor"
• Often talks excessively
• Perceived  immature 
• Accidents/injuries prone

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Impulsivity

• blurts out answers before questions completed
• difficulty waiting turn
• interrupts or intrudes on others
• Impatient
• Rushing into things
• Risk taking Taking dares

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DSM IV Criteria

• A
• 6 / 9 inattention
• /or
• 6 / 9 hyperactivity impulsivity
• 6 months maladaptive inconsistent with
  development level
• B symptoms before age of 7
• C impairment in 2 settings
• D clinically significant social/academic
• E not better explained by something else

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Assessment

• History parents or caregivers,
• as well as a classroom teacher or other school
  professional
• Interview of child
• Parent and teacher ratings of ADHD-related
  behaviours
• Investigations - No clinical examination or lab
  tests are accepted as either rule in or rule
  out. Recommend vision hearing tested

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Assessment

• RATING SCALES
• - Not diagnostic screening test
• - Monitor response to interventions
• PSYCHOMETRICS
• - WISC/WIAT
• - CPT
• - TEA-Ch
• Others as indicated - Speech language
• Occupational therapy
• Auditory processing

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Differential Diagnosis
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Differential Diagnosis

• Hearing Loss
• Auditory processing
• Learning Disability
• Epilepsy
• CNS abnormality
• Metabolic

• Tourettes syndrome
• Tics
• Sleep apnoea
• Lead poisoning
• Hyperthyroidism
• Pin worms
• Autism

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Differential Diagnosis

• Emotional distress
• PTSD
• Oppositional Defiant Disorder
• Conduct Disorder

• Bipolar Disorder
• Anxiety Disorder
• Substance Abuse
• Depression

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LD VS. ADHD

• Lacks early childhood history of hyperactivity
• ADHD behaviours arise in middle childhood
• ADHD behaviours appear to be task- or
  subject-specific
• Not socially aggressive or disruptive
• Not impulsive or disinhibited

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ADHD VS. ANXIETY DISORDERS

• Not overly concerned with competence
• Not anxious or nervous
• Exhibit little or no fear
• Have no difficulty separating from parents
• Infrequently experience nightmares
• Inconsistent performance
• Not concerned with future
• Are not socially withdrawn
• May be aggressive
• May be able to pay attention if work is
  stimulating

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DEPRESSION VS. ADHD

• Not usually as active
• Marked changes in affect/mood
• Concentration problems have acute onset possibly
  following stress event
• Changes in eating and sleeping habits
• Loss of interest or pleasure in most activities

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ODD/CD VS. ADHD

• Lacks impulsive, disinhibited behaviour
• Able to complete tasks requested by others
• Resists initiating response to demands

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ODD/CD VS. ADHD

• Lacks poor sustained attention and marked
  restlessness
• Often associated with parental child management
  deficits or family dysfunction

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Child abuse victims are at increased risk of a
variety of child and adolescent psychiatric
diagnoses, including depression, anxiety, conduct
disorders, ODD, ADHD and substance abuse. Kaplan
et al Oct 1999
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Comorbidity
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As many as one-third of children diagnosed with
ADHD also have a co-existing condition.
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Comorbidity

• NEURO- DEVELOPMENTAL
• learning disorders
• language disorders
• cognitive impairment
• functionally significant soft neurological
  features

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Comorbidity

• EMOTIONAL-BEHAVIORAL
• lowered self esteem
• downward cycle
• school failure
• substance abuse
• antisocial behaviour
• violence

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Comorbidity

• Conduct problems (e.g., oppositional behaviour,
  lying, stealing, and fighting)
• Mood or anxiety problems
• Academic underachievement
• Specific learning disabilities
• Peer relationship problems

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Impact
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Impact

• Emotional
• Low self esteem
• Impaired self-regulation
• Relationship difficulties
• Cognitive
• Organizing planning and time management
• Learning delay
• Short term memory problems lack of focus
• Language/speech
• Physical
• Fine gross motor skill delay
• Behaviour
• Impaired self-regulation

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Impact

• Pervasiveness of symptoms
• Persistence of symptoms
• Associated problems
• Aggression
• Psychosocial dysfunction peers, family
• Poor academic achievement
• Drug or alcohol use
• Criminal activity

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Impact

• Good family support
• Higher intelligence
• Good peer relationships
• Positive temperament, nonaggressive
• Emotional health, positive self-esteem
• Socio-economic factors
• Diminution or resolution of symptoms

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Impact

• 32-40 of students with ADHD drop out of school
• Only 5-10 will complete college
• 50-70 have few or no friends
• 70-80 will under-perform at work
• 40-50 will engage in antisocial activities
• More likely to experience teen pregnancy
  sexually transmitted diseases
• Have more accidents speed excessively
• Experience depression personality disorders
• 
  (Barkley,
  2002)

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School difficulties ADHD

• High rates of disruptive behaviour
• Low rates of engagement with academic instruction
  and materials
• Inconsistent completion and accuracy on
  schoolwork
• Poor performance on homework, tests, long-term
  assignments
• Difficulties getting along with peers teachers

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Life Impairments

• Childhood
• Academic and social issues
• Adolescence
• Substance abuse, driving accidents
• Teen pregnancies, dont finish school
• Young Adults
• Poor job stability, disrupted marriages
• Financial difficulties, impulsive crimes

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Management
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Psychological Psychiatric
Educational
Behavioural parent training programmes
Substance abuse
Multidisciplinary Management of ADHD
Other individually determined strategies
Coaching
Medical
Dietary
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Management

• Psychoeducational
• Family School
• Environmental
• dietary modifications
• parenting
• Academic skills training
• Psychological
• Cognitive Behavioural
• Medication

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Non-Pharmacological Management

• Family Therapy may be required for reasons such
  as difficulty raising managing a child with
  ADHD and new roles for individuals within the
  family.
• ADHD in parents may impact success of parent
  training and family therapy

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Non-Pharmacological Management

• Diet
• Elimination diets difficult
• Omega 3 at least 1000mg/day for a month
• Academic skills training focus on following
  directions, becoming organized, using time
  effectively, checking work, taking notes

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Non-Pharmacological Management

• Behavioural therapy
• - Does not reduce symptoms
• May improve social skills and compliance
• Does not lead to maintenance of gains or
  improvement over time after the therapy is
  completed
• Social skills group
• Uses modelling, practice, feedback and contingent
  reinforcement to address the social deficits
  common in children with ADHD
• Useful for the secondary effects of ADHD, such as
  low self-esteem, but not helpful for core
  symptoms of ADHD

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MEDICATIONS FOR ADHD

• Stimulant Medications
• Methylphenidate (Ritalin, Ritalin LA, Concerta)
• Dexamphetamine
• Non-stimulant
• Atomoxetine (Strattera)
• Other
• Clonidine (Catapres)
• Risperidone (Risperdal)

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MEDICATIONS FOR ADHD

• Tricyclic Antidepressants
• Desipramine Imipramine (Tofranil)
• Other Antidepressants
• Bupropion (Zyban) Fluoxetine (Prozac)

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Stimulants

• Used to treat ADHD since 1960s
• 200 placebo controlled studies over 40 years
• Best studied and most frequently prescribed
• Precise mechanism of action not known
• Blockade of pre-synaptic dopamine transporter
• Beneficial effects seen almost immediately

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Stimulants

• Methylphenidate
• Ritalin 10mg (3-4 hours)
• Ritalin LA 20/30/40 mg (6-8 hours)
• Concerta 18/36/54 mg(10-12 hours)
• Amphetamine
• Dexamphetamine 10 mg (3-4 hours)

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Stimulants Specific Effects

• Improved sustained attention
• Reduced distractibility
• Improved short-term memory
• Reduced impulsivity
• Reduced motor activity
• Decreased excessive talking
• Reduced bossiness and aggression with peers

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Stimulants Specific Effects

• Increased amount accuracy of academic work
  completed
• Decreased disruptive behaviour
• Improved handwriting and fine motor control
• Reduced off-task behaviour in classroom
• Improved ability to work and play independently
  as many as 75 of kids on these medications show
  improvement
• also seems to cause improvement in kids without
  ADHD in terms of attention and classroom
  behaviour

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Stimulants

• Not the only treatment needed, but effective in
  75-90 of ADHD cases (7 through adult years).
• Side effects few, rarely serious, usually
  manageable.
• Response to stimulants is NOT diagnostic of ADHD

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Stimulants

• Effective during school and homework-time
• Out of the system by bedtime
• May use Monday to Friday or 7 days /week
• Weekend use if significant behavioural
  comorbidity or needed for weekend activity
• Theoretical could worsen epilepsy
• Not addictive
• Use does not predispose to subsequent substance
  abuse protective

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SIDE EFFECTS OF STIMULANTS

• Insomnia
• Decreased Appetite (in 50-60) gtWeight Loss
• 1-2 cm shorter by end of growth
• Headaches
• Stomach aches (20-40)
• Mood lability/dysphoria
• Prone to Crying (10) sensitive

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SIDE EFFECTS OF STIMULANTS

• Nervous Mannerisms (10)
• Tics (lt5) and Tourettes (Very Rare) - possible
  exacerbation or uncovering of tics
• Over focused behaviour Cognitive toxicity
• (Mild) Increases in Heart Rate and Blood Pressure
• - NO INCREASE IN SUDDEN DEATH

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Atomoxetine (Strattera)

• Potent pre-synaptic, noradrenergic transport
  blocker with low affinity for other
  neurotransmitters
• Structurally similar to Fluoxetine
• Metabolized by CYP 2D6 system
• Half-life 4-5 hours
• Optimal effects seen at 2 weeks

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Atomoxetine (Strattera)

• May be given as single daily dose or bd
• Dispensed in a capsule that cannot be opened
• Superior to placebo, but no good data comparing
  efficacy to stimulants yet exists

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Atomoxetine - Indications

• Severe side effects to Methylphenidate/Dexamphetam
  ine weight loss insomnia
• If comorbidity anxiety mood disorders tics
  substance abuse

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Atomoxetine (Strattera)

• Adverse effects 5
• Sedation
• Nausea and vomiting
• Decreased appetite
• Modest increase in pulse and blood pressure
• Irritability, mood swings
• Fatigue
• Urinary hesitancy/prostatism (3)
• Suicidal ideation

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Atomoxetine (Strattera)

• Suicidal Ideation black box warning
• 2200 in study 1300 on Strattera
• 5 reported suicidal thoughts
• No deaths

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Treatment Implications

• More formulations now exist, use of which
  involves the art of medicine.
• Individualize medication for target symptoms,
  target times
• Stimulants outperform non-drug interventions but
  combination (drug non-drug therapy) is best and
  permits lower drug doses.

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Hyperactivity and impulsivity are among the most
important personality or individual difference
factors that predict later delinquency. Farringto
n 1996
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Disruptive Behaviour Disorders

• OPPOSITIONAL DEFIANT DISORDER
• Characterized by repeated arguments with adults,
  loss of temper, anger, and resentment
• Children with this disorder ignore adult requests
  and rules, try to annoy people, and blame others
  for their mistakes and problems
• Between 2 and 16 of children will display this
  pattern

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Disruptive Behaviour Disorders

• CONDUCT DISORDER violate rights of others
• Aggression to people / animals
• Conduct causing property loss or
• damage
• Deceitfulness or theft
• Serious rule violation

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Disruptive Behaviour Disorders

• Cases of conduct disorder have been linked to
  genetic and biological factors, drug abuse,
  poverty, traumatic events, and exposure to
  violent peers or community violence
• They have most often been tied to troubled
  parent-child relationships, inadequate parenting,
  family conflict, marital conflict, and family
  hostility

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Disruptive Behaviour Disorders

• Because disruptive behaviour patterns become more
  locked in with age, treatments for conduct
  disorder are generally most effective with
  children younger than 13
• Given the importance of family factors in this
  disorder, therapists often use family
  interventions

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Disruptive Behaviour Disorders

• Sociocultural approaches such as residential
  treatment programs have helped some children
• Individual approaches are sometimes effective as
  well, particularly those that teach the child how
  to cope with anger
• Recently, the use of drug therapy has been tried
• Institutionalization in juvenile training centres
  has not met with much success and may, in fact,
  increase delinquent behaviour

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Disruptive Behaviour Disorders

• It may be that the greatest hope for reducing the
  problem of conduct disorder lies in early
  intervention programs that begin in early
  childhood.
• These programs try to change unfavourable social
  conditions before a conduct disorder is able to
  develop.

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The latest analyses from the Dunedin longitudinal
study show hyperactivity in combination with CD
or CD symptoms is clearly the most important risk
factor for becoming a serious persistent offender
in adulthood. Prof T Moffitt, Maudsley Hospital