1. Disruptive Behaviour Disorders
Donna Dowling
Child & Adolescent Psychiatrist
Townsville CAYAS

2. ADHD (= ADD)
Oppositional Defiant Disorder
Conduct Disorder

3. Epidemiology

4. 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

5. Aetiology

7. 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

8. Main Neurotransmitters in ADHD
Dopamine
Noradrenaline
To regulate the inhibitory influences in the frontal-cortical processing of information

9. Dopamine
- enhances signals - improves:
. attention, . focus vigilance, . acquisition, . on-task behaviour and cognition

10. Noradrenaline
dampen « noise »
decrease distractibility and shifting
improve executive operations
increase behavioural, cognitive, motoric inhibition

11. 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

12. Diagnosing ADHD

14. 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
Daydreams
Can be very quiet & missed

15. 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

16. Impulsivity Impatient Rushing into things Risk taking; Taking dares
blurts out answers before questions completed
difficulty waiting turn
interrupts or intrudes on others
Impatient
Rushing into things
Risk taking; Taking dares

17. DSM IV Criteria A: B: symptoms before age of 7
6 / 9 inattention
&/or
6 / 9 hyperactivity & impulsivity
= 6 months; maladaptive & inconsistent with development level
B: symptoms before age of 7
C: impairment in 2 settings
D: clinically significant – social/academic
E: not better explained by something else

18. Assessment History – parents or caregivers, Interview of child
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

19. Assessment Others as indicated - Speech & language 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

20. Differential Diagnosis

21. Differential Diagnosis
Hearing Loss
Auditory processing
Learning Disability
Epilepsy
CNS abnormality
Metabolic
Tourette’s syndrome
Tics
Sleep apnoea
Lead poisoning
Hyperthyroidism
Pin worms
Autism

22. Differential Diagnosis
Bipolar Disorder
Anxiety Disorder
Substance Abuse
Depression
Emotional distress
PTSD
Oppositional Defiant Disorder
Conduct Disorder

23. 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

24. 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

25. 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

26. ODD/CD VS. ADHD Lacks impulsive, disinhibited behaviour
Able to complete tasks requested by others
Resists initiating response to demands

27. ODD/CD VS. ADHD Lacks poor sustained attention and marked restlessness
Often associated with parental child management deficits or family dysfunction

28. “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

29. Comorbidity

30. Comorbidity A.D.H.D. O.C.D. Substance Abuse O.D.D. ‘Dyspraxia’ C.D.
‘Dyslexia’
Tics/ Tourettes
Anxiety/
Depression
Speech &
Language
‘Dyspraxia’
Substance Abuse
A.D.H.D.
Bipolar Disorder
Asperger’s Syndrome
Sleep Disorders

31. As many as one-third of children diagnosed with ADHD also have a co-existing condition.

32. Comorbidity NEURO- DEVELOPMENTAL learning disorders language disorders
cognitive impairment
functionally significant ‘soft’ neurological features

33. Comorbidity EMOTIONAL-BEHAVIORAL lowered self esteem downward cycle
school failure
substance abuse
antisocial behaviour
violence

34. Comorbidity
Conduct problems (e.g., oppositional behaviour, lying, stealing, and fighting)
Mood or anxiety problems
Academic underachievement
Specific learning disabilities
Peer relationship problems

35. Impact

36. Impact Emotional 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

37. Impact Pervasiveness of symptoms Persistence of symptoms
Associated problems:
Aggression
Psychosocial dysfunction: peers, family
Poor academic achievement
Drug or alcohol use
Criminal activity

38. 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

39. 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)

40. 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

41. Life Impairments Childhood Adolescence Young Adults
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

42. Management

43. Multidisciplinary Management of ADHD
Psychological Psychiatric
Educational
Behavioural & parent training programmes
Substance abuse
Multidisciplinary Management of ADHD
Other individually determined strategies
Coaching
Dietary
Medical

44. Management Psychoeducational Environmental Academic skills training
Family; School
Environmental
dietary modifications
parenting
Academic skills training
Psychological
Cognitive; Behavioural
Medication

45. 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

46. 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

47. 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

51. MEDICATIONS FOR ADHD
Stimulant Medications
Methylphenidate (Ritalin, Ritalin LA, Concerta)
Dexamphetamine
Non-stimulant
Atomoxetine (Strattera)
Other
Clonidine (Catapres)
Risperidone (Risperdal)

52. MEDICATIONS FOR ADHD
Tricyclic Antidepressants
Desipramine ;Imipramine (Tofranil)
Other Antidepressants
Bupropion (Zyban); Fluoxetine (Prozac)

53. 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

54. 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)

55. 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

56. 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

57. 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

58. 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’

59. SIDE EFFECTS OF STIMULANTS
Insomnia
Decreased Appetite (in 50-60%) =>Weight Loss
1-2 cm shorter by end of growth
Headaches
Stomach aches (20-40%)
Mood lability/dysphoria
Prone to Crying (10%) ‘sensitive’

60. SIDE EFFECTS OF STIMULANTS
Nervous 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

61. 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

62. 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

63. Atomoxetine - Indications
Severe side effects to Methylphenidate/Dexamphetamine – weight loss; insomnia
If comorbidity – anxiety & mood disorders; tics; substance abuse

64. 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

65. Atomoxetine (Strattera)
Suicidal Ideation – black box warning
2200 in study; 1300 on Strattera
5 reported suicidal thoughts
No deaths

66. 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.

67. “Hyperactivity and impulsivity are among the most important personality or individual difference factors that predict later delinquency.”
Farrington 1996

69. 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

71. Disruptive Behaviour Disorders
CONDUCT DISORDER – violate rights of others
Aggression to people / animals
Conduct causing property loss or
damage
Deceitfulness or theft
Serious rule violation

72. 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

73. 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

74. 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

75. 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.

76. 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