ADHD/ODD/CD/Tic Disorders
Back to Basics
April 15, 2010
Clare Gray MD FRCPC
Attention Deficit Hyperactivity Disorder 3 - 7% school aged children male:female 3-6 : 1 Diagnostic Triad
– Inattentiveness– Impulsivity– Hyperactivity
Inattentive Symptoms
6 or more, for 6 months or more
Fails to give close attention to details or makes careless mistakes
Often has difficulty sustaining attention Often doesn’t seem to listen Often doesn’t follow through on instructions
or fails to finish schoolwork, chores
Inattentive Symptoms
Often has difficulty organizing tasks and activities
Often loses things necessary for tasks and activities
Often easily distracted by extraneous stimuli
Often forgetful in daily activities
Hyperactivity Symptoms
Often fidgets, squirms in seat Often leaves seat in classroom Often runs about or climbs excessively Often has difficulty playing quietly “on the go” or often acts as if “driven by
a motor” Often talks excessively
Impulsivity Symptoms
Often blurts out answers before questions have been completed
Often has difficulty awaiting turn Often interrupts or intrudes on others
ADHD
Onset before 7 years old impairment in 2 or more settings significant impairment in functioning symptoms not due to another
psychiatric disorder (PDD, Schizophrenia, Mood disorder, Anxiety disorder, Dissociative or PD)
ADHD
Types– Combined Type– Predominantly Inattentive Type– Predominantly Hyperactive/Impulsive Type– NOS
ADHD
Diagnosis of exclusion based on history can use Connors Rating Scales
completed by parents and teachers importance of multiple sources of
information about the child in different settings
ADHD
Treatment– Medication– Psychosocial treatments
ADHD Treatment
Medications– Stimulants– Antidepressants– Clonidine– Atypical antipsychotics
Stimulants
Methylphenidate – Ritalin (regular, slow release)– OROS Methylphenidate (Concerta)– Biphentin
Dextroamphetamine – Dexedrine (regular, slow release)
Adderall XR– Mixed amphetamine salts
Contraindications to Stimulants
Previous sensitivity to stimulants Glaucoma Symptomatic cardiovascular disease Hyperthyroidism Hypertension MAO inhibitor Use very carefully if history of substance
abuse
Stimulants
Monitor Carefully if:– Motor tics– Marked anxiety– Tourette’s syndrome– Seizures– Very young (3-6 year olds)
Stimulants -- Side Effects
Delay of sleep onset Reduced appetite Weight loss Tics Stomach ache Headache Jitteriness
Effectiveness of Stimulants
At least 70% response rate to first stimulant tried
Others
Buproprion (Wellbutrin)– Atypical antidepressant– NE and DA reuptake inhibitor– Lowers seizure threshold
Atomoxetine (Strattera)– SNRI– Takes 1 to 4 weeks for effects– “24 hour” coverage
ADHD
Psychosocial treatments– parent training
• psychoeducation, behaviour management, support
– school interventions• remediation, behaviour management,
– individual therapy • anger management, supportive, CBT,
psychoedn
Oppositional Defiant Disorder
Key feature– pattern of negativistic, hostile and defiant behavior
toward authority figures DSM IV criteria
– 8 types of behaviour– require 4 or more of these lasting at least 6
months– causing clinically significant impairment in
functioning• Behaviours happen more frequently than would be
typical for the patient’s age and developmental level
DSM IV Criteria
8 criteria– often loses temper– often argues with adults– often actively defies adults’ requests or rules– often deliberately annoys people– often blames others for his/her misbehavior– often is easily annoyed by others– often is angry and resentful– often is spiteful or vindictive
ODD -- Diagnosis
Important not to confuse ODD with normal development
toddlers and adolescents go through oppositional phases
behaviors occur in patient more frequently than with peers at same developmental level
ODD - Epidemiology
prevalence rates (lots of different data!)• 1 - 16 %
more common in males• 2:1 males:females
onset usually by 8 years of age
Etiology – Biological Factors
Parent with DBD, mood disorder, substance abuse disorder
Maternal smoking during pregnancy Abnormalities of prefrontal cortex Altered 5HT, NA and DA
Etiology – Psychological Factors
Poor relationship with parents (insecure attachment)
Neglectful/absent parent Difficulty or inability to form social
relationships
Etiology – Social Factors
Poverty Chaotic environment (lack of structure) Lack of parental supervision Lack of positive parental involvement Inconsistent discipline Abuse/neglect
ODD -- Management
Few controlled studies Variety of options
– behavior therapy– family therapy– parent management training
Treat comorbidities (ADHD)
Conduct Disorder
A persistent pattern of behavior in which the rights of others and/or societal norms are violated
DSM IV -- 4 categories of behavior– aggression to people and animals– destruction of property– deceitfulness or theft– serious violation of rules
aggression to people and animals
Often bullies, threatens or intimidates others Often initiates physical fights Has used a weapon that can cause serious
physical harm to others Has been physically cruel to people Has been physically cruel to animals Has stolen while confronting a victim Has forced someone into sexual activity
destruction of property
Has deliberately engaged in fire setting with the intention of causing serious damage
Has deliberately destroyed others’ property
deceitfulness or theft
Has broken into someone else’s house, building or car
Often lies to obtain goods or favors or to avoid obligations
Has stolen items of nontrivial value without confronting a victim
serious violation of rules
Often stays out at night despite parental prohibitions, beginning before age 13 years
Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
Is often truant from school, beginning before 13 years
CD -- Diagnosis
need to have 3 or more of these behaviors in the previous 12 months, with at least 1 criteria present in past 6 months
impairment in functioning If >18 y.o., criteria not met for ASPD Subtypes
– early (childhood) onset– late (adolescent) onset
CD -- Subtypes
Childhood-Onset (onset of at least one criterion prior to age 10 years)– usually more aggressive, usually male– poor peer relationships– these are the ones that are more likely to
go on to Antisocial PD
CD -- Subtypes
Adolescent-Onset (absence of any criteria prior to age 10 years)– tends to be less severe– less aggressive– better peer relationships– more often female– lower male:female ratio
Associated Features
Little empathy Little concern for feelings and well being
of others Misperceive the intentions of others as
hostile and threatening Callous Lack remorse or guilt (other than as a
learned response to avoid punishment
Only 3 risk factors have been shown to be “causal”– harsh, inconsistent parenting– poor academic performance– exposure to parental discord
CD -- Etiology
Combination of genetic and environmental factors
Risk for CD is increased in children with– a biological or adoptive parent with ASPD– a sibling with CD
Environmental factors– poor family functioning (poor parenting, marital
discord, child abuse)– family history of substance abuse,mood d/o,
psychotic d/o, ADHD, LD, CD and Antisocial PD
Antisocial Personality Disorder
Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years
3 or more of:– Failure to conform to social norms with respect to
lawful behaviours – repeatedly performing acts that are grounds for arrest
– Deceitfulness, repeated lying, use of aliases or conning others for personal profit or pleasure
– Impulsivity or failure to plan ahead
Antisocial Personality Disorder
– Irritability and aggressiveness, repeated physical fights or assaults
– Reckless disregard for safety of self or others– Consistent irresponsibility – repeated failure to
sustain consistent work behaviour or honour financial obligations
– Lack of remorse – being indifferent to or rationalizing having hurt, mistreated or stolen from another
Antisocial Personality Disorder
At least 18 years of age Evidence of CD, with onset before age
15 years Not due to Schizophrenia or Mania
CD -- Course
< 50% of CD have severe and persistent antisocial problems as adults
CD – Protective Factors
easy temperament above average intelligence competence at a skill a good relationship with at least 2
caregiving adult
CD -- Management
4 treatments that show the most promise for treating CD based on good studies that have been replicated– cognitive problem solving skills training– parent management training– family therapy– multisystemic therapy
CD -- Management
Pharmacological– to treat comorbid conditions
• ADHD – stimulants • Depression - SSRIs• Anxiety - SSRIs
– to treat CD alone• Impulsivity/Aggression - mood stabilizers,
neuroleptics
Tics
a part of the body moves repeatedly, quickly, suddenly and uncontrollably
can occur in any body part, such as the face, shoulders, hands or legs
Sounds that are made involuntarily (such as throat clearing) are called vocal tics
Most tics are mild and hardly noticeable. in some cases they are frequent and severe,
and can affect many areas of a child's life.
Tics
5 to 24% of all school age children have had tics at some stage during this period
Tics appear to get worse with emotional stress and are absent while sleeping.
Transient Tic Disorder
The patient has vocal or motor tics,or both. They can be single or multiple.
For at least 4 weeks but no longer than 12 consecutive months, these tics have occurred many times each day, nearly every day.
These symptoms cause marked distress or materially impair work, social or personal functioning.
They begin before age 18. The symptoms are not directly caused by a general medical
condition (such as Huntington's disease or a postviral encephalitis) or to substance use (such as a CNS stimulant).
The patient has never fulfilled criteria for Tourette’s Disorder or
Chronic Motor or Vocal Tic Disorder
Chronic Tic Disorder
Single or multiple motor or vocal tics, but not both, have been present at some time during the illness.
The tics occur many times a day nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
The onset is before age 18 years. The disturbance is not due to the direct physiological effects of a
substance or a general medical condition Criteria have never been met for Tourette’s Disorder
Tourette’s Disorder
Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently
The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
The onset is before age 18 years. The disturbance is not due to the direct physiological
effects of a substance or a general medical condition.
Treatment
Depends on – severity, – the distress it causes to the patient– the effects the tics have on school or job
performance. Medication and psychotherapy are used
only when there is substantial interference with ordinary activities.
Treatment
Neuroleptics– Pimozide.– Risperidone.
Other options– Clonidine
Treatment
Habit-reversal training (HRT)– Awareness training
• accentuates sensitivity to tic sensations
– Competing response training• taught a specific response pattern that would
be incompatible with the tic• replaces the tic behavior with a more
appropriate competing response
Antares is the 15th brightest start in the sky
It is more than 1000 light years away
So just try to keep everything in perspective!!
Good Luck with the Exam!
Any questions – [email protected]
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