Attention deficit hyperactivity disorder (ADHD), Conduct disorder

biological treatments

Professor Alasdair VanceHead, Academic Child PsychiatryDepartment of PaediatricsUniversity of MelbourneRoyal Children’s Hospital

Outline of presentation

1. ADHD, Conduct disorder: definition2. Key biological aetiological factors3. A model for intervention4. Key medication treatments

Prof. A. Vance

1. ADHD, Conduct disorder: definition

Diagnostic nosology-some comments:

DSM-IV definition of a mental disorder-

A mental disorder is conceptualized as

a clinically significantbehavioural pattern that occursin an individual

and

is associated with impairment inone or more areas of functioning

Prof. A. Vance

1. ADHD, Conduct disorder: definition

Diagnostic nosology-some comments

in children and adolescents-

impairment is developmentally inappropriate, judged relative to children of the same age, gender and IQin social, academic, occupational or other important areasof functioning

multi-informant reports required

Prof. A. Vance

1. ADHD, Conduct disorder: definition

Attention Deficit Hyperactivity Disorder (ADHD)DSM-IV CRITERIA

-six or more symptoms, at least six months, maladaptive/inconsistent with developmental level-inattention dimension and/or hyperactivity-impulsivity dimension-evident at least two settings-onset before seven years of age-impairment social, academic, occupational functioning-symptoms not due to a PDD, Psychotic, Mood, or Anxiety Disorder

Prof. A. Vance

1. ADHD, Conduct disorder: definition

TYPES of ADHD

-combined type-predominantly inattentive type-predominantly hyperactive-impulsive type

3-5% prevalence in primary school age children

Prof. A. Vance

1. ADHD, Conduct disorder: definition

COMORBIDITY of ADHD

-language-based Learning Disorders-Oppositional-Defiant through to Conduct Disorders-anxiety and depressive symptoms and/or Disorders-developmental coordination disorder

Prof. A. Vance

1. ADHD, Conduct disorder: definition

The Spectrum of Antisocial Behaviour(Steiner, 1999)

-antisocial behaviour

-criminality and delinquency

-antisocial behaviour and psychopathology

-persistent conduct problems

-conduct disorder

-psychopathyProf. A. Vance

1. ADHD, Conduct disorder: definition

Oppositional defiant disorder (ODD)

-a recurrent pattern of negativistic, defiant, and hostile behaviour

-onset usually before 7 years of age

-usually first emerges in the home setting

-always a precursor for Conduct disorder (approximately 3% ofchildren with ODD develop CD)

-prevalence (2%-16%) have been reported (Loeber et al. 2000)

Prof. A. Vance

1. ADHD, Conduct disorder: definition

Conduct disorder (CD)

-repetitive and persistent pattern of behaviour in whichthe basic rights of others and/or major age-appropriate normsor rules are violated, evidenced by three or more of the following criteria within the previous 12 months, with at leastone criterion present in the past 6 months:

Aggression/Cruelty towards people and/or animalsDestruction of propertyTheftSerious violations of social rules/norms

->/= 18 years of age, criteria for antisocial personality disorder not met

Prof. A. Vance

1. ADHD, Conduct disorder: definition

COMORBIDITY of ODD/CD

- ADHD, combined type, - language-based learning difficulties/disorders- depressive disorders

Prof. A. Vance

2. ADHD: Key biological aetiological factors

-Executive functioning deficits

Response disinhibition: motor and cognitionoptimise response speed and accuracy

Working memory deficits: verbal and visuospatialoptimise span and strategy

Prof. A. Vance

2. ADHD: Key biological aetiological factors

Mood dysregulation: decrease irritabilityincrease emotional salience

Arousal dysregulation: optimise physiological arousaloptimise habituation

Prof. A. Vance

Prof. A. Vance

Prof. A. Vance

2. Conduct disorder: Key biological aetiological factors

-neurobiology: hypo-arousal; hyper-arousal; irritability; lower verbal/performance IQ; executive function deficits-especially response inhibition and working memory

-comorbid substance abuse

-cognitive style-deficient and/or deviant

-behavioural models of socialisation-deficient and/or deviant

-peer influences, especially in late childhood/early adolescence

-comorbid anxiety and depressive symptoms

Prof. A. Vance

3. A model for intervention

-assessment and treatment focuses on delineation of risk factors andresilience factors-biologically (eg, executive function deficits; good arousal regulation) psychologically (eg, externalise blame; balanced critical self-reflection) and socially (eg, hostile critical interpersonal environment; confiding, nurturing consistent interpersonal environment)

-monitoring of these risk and resilience factors and their response totreatment through developmental phases

Prof. A. Vance

3. A model for intervention

-a practical approach

[A] psychological and social treatment approach implementedfor 4-6 weeks

key elements are the interpersonal milieu

making and keeping friends: two differentprocesses, why children have trouble- ‘causes’ of ‘no friends’,paying attention to others’ behaviour, getting along: using active listening and strategic ignoring, monitoring your own behaviour and others’ behaviour, resolving conflict and problem solving, coping with strong feelings in yourself and others, empathy skills and perspective taking, familycommunication, getting along better at home with brothers and sisters, anticipating future problems

3. A model for intervention

-a practical approach

[A] psychological and social treatment approach implementedfor 4-6 weeks

key elements are the intra-individual milieu

controlled breathing, muscle biofeedback,guided visual imagery

[B] key other vulnerabilities addressed – vision, hearing,specific verbal and/or visuospatial learning difficulties,developmental coordination difficulties

Prof. A. Vance

3. A model for intervention

- a practical approach

[C] medication use to facilitate availability of the young person to learn from the psychological and social interventions through

better mood regulationbetter arousal regulationbetter executive functioning

Prof. A. Vance

3. A model for intervention

Mood dysregulation: decrease irritabilityincrease emotional salience

Arousal dysregulation: optimise physiological arousaloptimise habituation

Executive functioning: optimise response speed and accuracyoptimise span and strategy

Prof. A. Vance

4. Key medication interventions

Mood dysregulation:

irritability SSRITCAantipsychotic medicationstimulant medication

emotional salience stimulant medicationSSRI?TCA?

Prof. A. Vance

4. Key medication interventions

Arousal regulation:

physiological arousal clonidinebenzodiazepinesTCAantipsychotic medication

habituation response clonidinebenzodiazepinesTCA?antipsychotic medication?

Prof. A. Vance

4. Key medication interventions

Executive functioning

Response inhibition:

motor and cognition stimulant medication-linear dose response

speed and accuracy clonidine higher dose

Working memory:

span stimulant medication-inverted parabolic response

strategy stimulant medication-linear dose responseclonidine higher dose

Prof. A. Vance

4. Key medication interventions

-start low, go slow, finish slow, although same optimal dosesare suggested

-children versus adults:

higher doses with more frequent dosingNB: increased distribution and more rapid clearanceNB: daily compliance issues

Prof. A. Vance

Prof. A. Vance

Prof. A. Vance