Disruptive Behaviour Disruptive Behaviour DisordersDisorders

Disruptive Behaviour Disruptive Behaviour DisordersDisorders

Donna DowlingDonna Dowling

Child & Adolescent PsychiatristChild & Adolescent Psychiatrist

Townsville CAYASTownsville CAYAS

•ADHD (= ADD)•Oppositional Defiant Disorder

•Conduct Disorder

EpidemiologyEpidemiologyEpidemiologyEpidemiology

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

AetiologyAetiologyAetiologyAetiology

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

Main Neurotransmitters in ADHD

• Dopamine• Noradrenaline

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

Dopamine

- enhances signals - improves:

. attention, . focus vigilance, . acquisition, . on-task behaviour and cognition

Noradrenaline• dampen « noise »

• decrease distractibility and shifting

• improve executive operations

• increase behavioural, cognitive, motoric inhibition

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/preservatives – not sugar per se

Diagnosing ADHDDiagnosing ADHDDiagnosing ADHDDiagnosing ADHD

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

DaydreamsCan be very quiet & missed

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

Impulsivity

• blurts out answers before questions completed

• difficulty waiting turn• interrupts or intrudes on others

Impatient Rushing into things Risk taking; Taking dares

DSM IV CriteriaA:• 6 / 9 inattention

&/or • 6 / 9 hyperactivity & impulsivity= 6 months; maladaptive & inconsistent with development level

B: symptoms before age of 7C: impairment in 2 settingsD: clinically significant – social/academicE: not better explained by something else

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

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•

Differential DiagnosisDifferential DiagnosisDifferential DiagnosisDifferential Diagnosis

Differential Diagnosis

• Hearing Loss• Auditory

processing• Learning Disability• Epilepsy• CNS abnormality• Metabolic

• Tourette’s syndrome

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

Differential Diagnosis

• Emotional distress

• PTSD• Oppositional

Defiant Disorder

• Conduct Disorder

• Bipolar Disorder

• Anxiety Disorder

• Substance Abuse

• Depression

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

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

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

ODD/CD VS. ADHD

• Lacks impulsive, disinhibited behaviour

• Able to complete tasks requested by others

• Resists initiating response to demands

ODD/CD VS. ADHD• Lacks poor sustained attention

and marked restlessness• Often associated with parental

child management deficits or family dysfunction

“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

ComorbidityComorbidityComorbidityComorbidity

ComorbidityO.C.D.

O.D.D.

C.D.

‘Dyslexia’

Tics/ Tourettes

Anxiety/Depression

Speech & Language

‘Dyspraxia’

Substance Abuse

A.D.H.D. Bipolar Disorder

Asperger’s Syndrome

Sleep Disorders

As many as one-third of children diagnosed with ADHD also have a co-

existing condition.

Comorbidity

NEURO- DEVELOPMENTAL• learning disorders• language disorders• cognitive impairment• functionally significant ‘soft’

neurological features

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

ComorbidityConduct problems (e.g., oppositional behaviour,

lying, stealing, and fighting)

Mood or anxiety problems

Academic underachievementSpecific learning disabilitiesPeer relationship problems

ImpactImpactImpactImpact

ImpactEmotional• 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

Impact• Pervasiveness of symptoms• Persistence of symptoms• Associated problems:

– Aggression– Psychosocial dysfunction: peers, family– Poor academic achievement– Drug or alcohol use– Criminal activity

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

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)

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

Life Impairments• Childhood

– Academic and social issues

• Adolescence– Substance abuse, driving accidents– Teen pregnancies, don’t finish school

• Young Adults– Poor job stability, disrupted marriages– Financial difficulties, impulsive crimes

ManagementManagementManagementManagement

Psychological Psychiatric Educational

Other individually determined strategies

MedicalDietary

Coaching

Behavioural & parent training programmes

Multidisciplinary Management of

ADHD

Substance abuse

Management

• Psychoeducational – Family; School

• Environmental– dietary modifications– parenting

• Academic skills training• Psychological

– Cognitive; Behavioural

• Medication

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

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

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

MEDICATIONS FOR ADHDStimulant Medications

–Methylphenidate (Ritalin, Ritalin LA, Concerta)

–DexamphetamineNon-stimulant

Atomoxetine (Strattera)Other

Clonidine (Catapres)Risperidone (Risperdal)

•

MEDICATIONS FOR ADHDTricyclic Antidepressants –Desipramine ;Imipramine (Tofranil)

Other Antidepressants–Bupropion (Zyban); Fluoxetine (Prozac)

Stimulants

• Used to treat ADHD since 1960’s• 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

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)

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

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

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

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’

SIDE EFFECTS OF STIMULANTS InsomniaDecreased Appetite (in 50-60%)

=>Weight Loss 1-2 cm shorter by end of growthHeadachesStomach aches (20-40%)Mood lability/dysphoria Prone to Crying (10%) ‘sensitive’

SIDE EFFECTS OF STIMULANTSNervous Mannerisms (10%)Tics (<5%) and Tourette’s (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

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

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

Atomoxetine - Indications• Severe side effects to

Methylphenidate/Dexamphetamine – weight loss; insomnia

• If comorbidity – anxiety & mood disorders; tics; substance abuse

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

Atomoxetine (Strattera)• Suicidal Ideation – black box

warning

2200 in study; 1300 on Strattera5 reported suicidal thoughtsNo deaths

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.

“Hyperactivity and impulsivity are among the most important

personality or individual difference factors that predict

later delinquency.”

Farrington 1996

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

Disruptive Behaviour Disorders

CONDUCT DISORDER – violate rights of others

• Aggression to people / animals

• Conduct causing property loss ordamage

• Deceitfulness or theft• Serious rule violation

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

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

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

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.

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