1. ADHD/ODD/CD/Tic Disorders
Back to Basics
April 15, 2010
Clare Gray MD FRCPC

2. Attention Deficit Hyperactivity Disorder
3 - 7% school aged children
male:female 3-6 : 1
Diagnostic Triad
Inattentiveness
Impulsivity
Hyperactivity

3. 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

4. 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

5. 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

6. Impulsivity Symptoms
Often blurts out answers before questions have been completed
Often has difficulty awaiting turn
Often interrupts or intrudes on others

7. 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)

8. ADHD Types Combined Type Predominantly Inattentive Type
Predominantly Hyperactive/Impulsive Type
NOS

9. 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

10. ADHD
Treatment
Medication
Psychosocial treatments

11. ADHD Treatment Medications Stimulants Antidepressants Clonidine
Atypical antipsychotics

12. Stimulants Methylphenidate Dextroamphetamine Adderall XR
Ritalin (regular, slow release)
OROS Methylphenidate (Concerta)
Biphentin
Dextroamphetamine
Dexedrine (regular, slow release)
Adderall XR
Mixed amphetamine salts

13. Contraindications to Stimulants
Previous sensitivity to stimulants
Glaucoma
Symptomatic cardiovascular disease
Hyperthyroidism
Hypertension
MAO inhibitor
Use very carefully if history of substance abuse

14. Stimulants Monitor Carefully if: Motor tics Marked anxiety
Tourette’s syndrome
Seizures
Very young (3-6 year olds)

15. Stimulants -- Side Effects
Delay of sleep onset
Reduced appetite
Weight loss
Tics
Stomach ache
Headache
Jitteriness

16. Effectiveness of Stimulants
At least 70% response rate to first stimulant tried

17. Others Buproprion (Wellbutrin) Atomoxetine (Strattera)
Atypical antidepressant
NE and DA reuptake inhibitor
Lowers seizure threshold
Atomoxetine (Strattera)
SNRI
Takes 1 to 4 weeks for effects
“24 hour” coverage

18. ADHD Psychosocial treatments parent training school interventions
psychoeducation, behaviour management, support
school interventions
remediation, behaviour management,
individual therapy
anger management, supportive, CBT, psychoedn

19. 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

20. 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

21. 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

22. ODD - Epidemiology prevalence rates (lots of different data!)%
more common in males
2:1 males:females
onset usually by 8 years of age

23. Etiology – Biological Factors
Parent with DBD, mood disorder, substance abuse disorder
Maternal smoking during pregnancy
Abnormalities of prefrontal cortex
Altered 5HT, NA and DA

24. Etiology – Psychological Factors
Poor relationship with parents (insecure attachment)
Neglectful/absent parent
Difficulty or inability to form social relationships

25. Etiology – Social Factors
Poverty
Chaotic environment (lack of structure)
Lack of parental supervision
Lack of positive parental involvement
Inconsistent discipline
Abuse/neglect

26. ODD -- Management Few controlled studies Variety of options
behavior therapy
family therapy
parent management training
Treat comorbidities (ADHD)

27. 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

28. 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

29. destruction of property
Has deliberately engaged in fire setting with the intention of causing serious damage
Has deliberately destroyed others’ property

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Only 3 risk factors have been shown to be “causal”
harsh, inconsistent parenting
poor academic performance
exposure to parental discord

37. 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

38. 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

39. 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

40. Antisocial Personality Disorder
At least 18 years of age
Evidence of CD, with onset before age 15 years
Not due to Schizophrenia or Mania

41. CD -- Course
< 50% of CD have severe and persistent antisocial problems as adults

42. CD – Protective Factors
easy temperament
above average intelligence
competence at a skill
a good relationship with at least 2 caregiving adult

43. 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

44. CD -- Management Pharmacological to treat comorbid conditions
ADHD – stimulants
Depression - SSRIs
Anxiety - SSRIs
to treat CD alone
Impulsivity/Aggression - mood stabilizers, neuroleptics

45. 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.

46. 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.

47. 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

48. 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

49. 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.

50. 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.

51. Treatment
Neuroleptics
Pimozide.
Risperidone.
Other options
Clonidine

52. 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

58. 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!!

59. Good Luck with the Exam!
Any questions –