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

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Presentation on theme: "ADHD/ODD/CD/Tic Disorders Back to Basics April 15, 2010 Clare Gray MD FRCPC."— Presentation transcript:

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 –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) –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 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

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58 Antares is the 15 th 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 –


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