Disruptive Behaviour Disorders Donna Dowling Child & Adolescent Psychiatrist Townsville CAYAS

ADHD (= ADD) Oppositional Defiant Disorder Conduct Disorder

Epidemiology

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

Aetiology

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

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

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

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

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

Diagnosing ADHD

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

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

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

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

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

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

Differential Diagnosis

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

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

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

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

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

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

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

“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

Comorbidity

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

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

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

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

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

Impact

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

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

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

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)

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

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

Management

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

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

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

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

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

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

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

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

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)

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

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

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

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’

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’

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

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

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

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

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

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

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.

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

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

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

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

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

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

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.

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