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
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:
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,
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
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
Tourettes
syndrome
Tics
Sleep apnoea
Lead poisoning
Hyperthyroidism
Pin worms
Autism
Differential
Diagnosis
Emotional
distress
PTSD
Oppositional
Defiant
Disorder
Conduct
Disorder


Bipolar
Disorder
Anxiety
Disorder
Substance
Abuse
Depression

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
O.C.D.
O.D.D.
C.D.
Dyslexia
Tics/
Tourettes
Anxiety/
Depression
Speech &
Language
Dyspraxia
Substance
Abuse
A.D.H.D.
Bipolar
Disorder
Aspergers
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
Impaired self-regulation

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
Academic and social issues
Adolescence
Substance abuse, driving accidents
Teen pregnancies, dont finish school
Young Adults
Poor job stability, disrupted marriages
Financial difficulties, impulsive crimes
Management
Psychological
Psychiatric
Educational
Other
individually
determined
strategies
Medical Dietary
Coaching
Behavioural &
parent training
programmes
Multidisciplinary
Management of ADHD
Substance
abuse
Management

Psychoeducational
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 1960s
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 Tourettes (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