ADHD

Conduct Disorder
School Refusal

Aathil
Kajan
Prasani
Attention Deficit Hyperactive Disorder
• Second most common psychiatric disorder in children.

• Over activity is not equal to ADHD.

• 1/3 of children are described as overactive by parents
• 5-20% of school children are described as overactive by teachers
• This over activity often varies in different situations

• ADHD – functionally impairing, persistent end of the spectrum of behavior

• DSM 5 – ADHD

• ICD 10 – Hyperkinetic disorder

Clinical features

• Three core features

• Inattention - having difficulty paying attention

• Hyperactivity - too much energy or moving and talking too much

• Impulsivity - acting without thinking or having difficulty with self-control

• Many children develop minor forms of antisocial behavior
• Disobedience
• Temper tantrums
• Aggression

• These children are often socially disinhibited

• Susceptible to bullying

• Have fluctuating moods

• Low self-esteem and depressive mood are common
Diagnostic criteria

ICD 10 – Hyperkinetic disorder DSM 5 – ADHD

• Cardinal features • Cardinal features

• Inattention • Inattention
• Hyperactivity • Hyperactivity
• Impulsivity • Impulsivity
• Lasting for at least 6 months • Lasting for at least 6 months
• Evident in more than one place (home, • Evident in more than one place (home,
school) school)
• Symptoms started before 6 years • Symptoms started before 12 years
• Requires both inattention and hyperactivity • Requires either inattention or hyperactivity
and impulsivity
Comorbidity and associated conditions
• 50% of ADHD children meet the diagnostic criteria for other
conditions also

• Oppositional defiant disorder

• Conduct disorder
• Depressive disorder
• Anxiety disorder
• ? ASD [autism spectrum disorder] in ADHD
• Specific learning difficulties
• Poor motor coordination
Epidemiology
• World wide point prevalence rates of childhood ADHD

• 2.2% in males

• 0.7% in females
Aetiology
• Disorder of higher cognitive executive function
• Both heritable and non heritable factors
• abnormalities of neuro transmission in the prefrontal cortex and associated subcortical structures.
• Severe traumatic birth injury
• Structural and functional abnormalities in brain
• Reduction in volume and cortical thickness in some areas (basal ganglia)
• Prefrontal, Striatal and cerebellum
• White matter distruption
• Disordered connectivity between various brain regions
• Genetics
• Heritability ̴ 70-80%
• First degree relatives
• Monozygotic > Dizygotic
Other factors
• Early psychosocial adversity
• Maternal alcohol or substance usage during pregnancy
• Low birth weight
• Prematurity
• Nutritional deficiencies
• Exposure to environmental toxins
Prognosis
• Inattention and impulsiveness persist
• But hyperactivity often ceases by puberty
• If the hyperactivity is severe and accompanied by learning failure and
low intelligence the prognosis is poor, condition may persist to
adulthood, as
• Antisocial disorder
• Drug misuse
Adult ADHD
• No longer meet the criteria for diagnosis
• But majority will have functional impairment
• In DSM 5 symptoms required are reduced (to increase the detection)
• Usually have
• Procrastination
• Poor motivation
• Mood lability
• Irritability
• Inattention lead to problems with work and social relationships
• Poor organization
• Comorbid mood disorders and substance misuse are common
• Psychostimulants and atomoxetine are effective
Management
• Assess the patient
• History & SNAP IV rating scale
• Treatment
• Psychosocial interventions
• Pharmacological treatment(Improves 3 core symptoms)
SNAP IV Teacher Parent rating scale
Psychosocial intervention
• Psycho education & Parent training
• Behavioural therapy
• Praise or reward for appropriate behaviour
• Ignore the mild inappropriate behaviour
• Don’t punish them
• Use appropriate commands
• Daily chart and points system
• Specific class room intervention
• Child sit near the teacher
• Setting shorter assignment for the child
• Allowing the child to get up & run about at set interval through out the day
• Social skill training
• Listen & engage in conversation
• Enter new group situations
• Give & receive praise & criticism
• Cope with frustration

• Cognitive behaviour training

• Benefit for those with comorbid anxiety or depressive disorder

• Dietary advices– free fatty acid supplementatation, restriction of artificial

food colourants
Pharmacotherapy
• Hypothetically low strength of NE/DA
in the PFC
• Thus treatment should be aimed
towards Increasing the prefrontal
DA/NE
• Drugs used in ADHD
• Methylphenidate – stimulants –
increase DA + NE
• Dexamphetamine – stimulant drug
• Atomoxetine – NRI – increases NE
• Clonidine – alpha – 2 agonist
• When a drug is indicated, methylphenidate is usually the first choice

• Dexamphetamine and Atomoxetine are first line alternatives

• Stimulant

• Methylphenidate (common)

▪ 1st line drug

▪ Increase central DA and NA levels
▪ Increased release of DA in the nucleus accumbens
▪ NE and DA in the prefrontal cortex by blocking the reuptake pumps
• Short acting and long acting are available
• Short acting form
Onset of action within 30min to1 hr, action lasts for 2 to 4 hrs
• Dosage according to body weight (0.5-1mg/kg)
• Starting dose 5 to 10 mg /day, Maximum dose 2.1mg/kg/day
• SE; Irritability , Depression, insomnia, poor appetite, worsens tic disorder

• Dexamphetamine also similar (less common)

• Non stimulant :
• Atomoxetine – NA reuptake inhibitor
• Side effects
-Transitory gastrointestinal symptoms: LOA, Nausea, Abdominal pain, liver
damage
-Sleep problems, increased heart rate and blood pressure
-Severe very rare side effects include hepatotoxicity, with increase in hepatic
enzymes, bilirubin and jaundice and increased suicidal thoughts
• Suitable with comorbid tic disorder & non responders to stimulant

• Other drugs :
1. Clonidine :
• Alpha-2 agonists with demonstrated efficacy in the treatment of ADHD.
• Can also be used for patients with comorbid tic disorders/Tourette’s
syndrome, in which its efficacy seems to be higher.
2. Imipramine
3. Bupropion
• Monitor height & weight, BP, PR in each follow up visit(6monthly)

• Drug free day

• To minimise side effect
• To check the child still need the drug
• Better avoided in holidays and weekend
Dietary advice
• Give free fatty acid supplementation– Omega 3 FA, Eicosa pentaenoic
acid,Docosa hexaenoic acid
• Restrict artificial food colouring.
• Elimination of certain foods suspected to have influence on behaviour
• May impact on final height
• Only minor proportion benefitted
Conduct disorder (CD)
Conduct disorders are characterized by
antisocial behaviours outside of socially acceptable norms and
often intrude on other people's expectation or rights.
Prevalence
• CD accounts for about 5% to 10% prevalence .
ODD – a diagnosis given to younger children
CD – for older children and adolescents

• The criteria for diagnosis are almost same for both.

• ODD – M:F = 2:1 CD Males ×3-7 times than female

• prevalence rates are high in children,

- from low socioeconomic status
- Who have been maltreated
- brought up in residential care
- transferred to foster care
- with intellectual disabilities
Clinical features

In pre school period

- Defiance (open resistance, bold disobedience)

- Disobedience
- Temper tantrums
- Physical aggression towards siblings or adults
- Destructiveness
In later childhood
- stealing
- Lying
- Disobedience with verbal & physical aggression
Later those children,
can go for alcohol or drug abuse, delinquency and reckless behaviour.

Small proportion of children with CD present with sexual behavior which

frequent unprotected sex and pregnancy can be a problem in adolescent
girl
F9.1 conduct disorders ICD-10
Repetitive and persistent pattern of dissocial,aggressive or defiant conduct
for more than 6 months
F91.0 conduct disorders confined to family context
F91.1 Unsocialized conduct disorders
F91.2 socialized conduct disorders
F91.3 oppositional defiant disorders
Factors predict poor outcome in children with conduct disorder
Young children
- early onset ( before age of 8 years)
- severe frequent and varied antisocial behaviour
- hyperactivity and attention problem
- low IQ
- pervasiveness

in the family
- parental criminality and alcoholism
- High hostility/ discord focused on the child
- Harsh inconsistent parenting
- low income
In the wider environment
- Economically deprived area
- Ineffective school
Management
• Parent training programs
- Mainstay of treatment which use behavioral principles
- Taught how to praise & reward, & how to set limits for abnormal
behaviour

• Anger management

• Interventions in school

• treat coexisting disorders( eg- ADHD, depression)

SCHOOL REFUSAL
Not a psychiatric disorder

Pattern of behavior- Associated with anxiety and depressive disorders

Prevalence 1-2% in general population,

15% in children referred to psychiatry
• Peaks in 3 age groups
• 6 years – on starting school
• 11 years – with change of school
• 14 years

• M=F
Clinical features
• Child’s sudden and complete refusal to attend school
• Reluctance to set out, increasing unhappiness and anxiety when it’s time to go
• Somatic symptoms of anxiety:
- Headaches, abdominal pain, diarrhea, sickness, vague complaints of
feeling ill
• Occur on school days, not on other days
• Distress increases when reaching school
 Aetiology
• Problems at
• School – bullying, punitive teachers, poor school performance,
abuse, change in school/class
• Home – domestic violence, parental illness

• In young children – separation anxiety

• Depression

• Social phobia
In older children
• Psychosis (rarely)
 School
refusal
More anxiety Frequent
about school absenteeism
from school
- Getting behind schoolwork
- No contact with friends
leading to friendship
breakdowns
 Management
• Send the child back to school as soon as possible

• Behavioural management
• Rewarding the days the child goes to school
• Graded exposure to school
• Avoid rewarding staying at home – if at home get the child to
do the school work

• Liaison with the school

• Help to catch up missed school work

• Relaxation strategies to manage anxiety at school