ADHD/ODD/CD

Back to Basics

April 24, 2008

Clare Gray MD FRCPC

Attention Deficit Hyperactivity Disorder 3 - 7% school aged children male:female 3-6 : 1 Diagnostic Triad

– Inattentiveness– Impulsivity– Hyperactivity

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

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

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

Impulsivity Symptoms

Often blurts out answers before questions have been completed

Often has difficulty awaiting turn Often interrupts or intrudes on others

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)

ADHD

Types– Combined Type– Predominantly Inattentive Type– Predominantly Hyperactive/Impulsive Type– NOS

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

ADHD

Treatment– Medication– Psychosocial treatments

ADHD Treatment

Medications– Stimulants– Antidepressants– Clonidine– Atypical antipsychotics

Stimulants

Methylphenidate – Ritalin (regular, slow release)– OROS Methylphenidate (Concerta)

Dextroamphetamine – Dexedrine (regular, slow release)

Adderrall XR– Mixed amphetamine salts

Contraindications to Stimulants

Previous sensitivity to stimulants Glaucoma Symptomatic cardiovascular disease Hyperthyroidism Hypertension MAO inhibitor Use very carefully if history of substance

abuse

Stimulants

Monitor Carefully if:– Motor tics– Marked anxiety– Tourette’s syndrome– Seizures– Very young (3-6 year olds)

Stimulants -- Side Effects

Delay of sleep onset Reduced appetite Weight loss Tics Stomach ache Headache Jitteriness

Effectiveness of Stimulants

At least 70% response rate to first stimulant tried– Fewer than half show total normalization

Others

Buproprion (Wellbutrin) Atomoxetine (Strattera)

ADHD

Psychosocial treatments– parent training

• psychoeducation, behaviour management, support

– school interventions• remediation, behaviour management,

– individual therapy • anger management, supportive, CBT,

psychoedn

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

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

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

ODD -- Epidemiology

prevalence rates (lots of different data!)• 2 - 16 %

more common in males• 2:1 or 3:1 males:females

peak age of onset• 6.5 years• cases rarely onset after age 10

ODD -- Etiology

Etiology is “multifactorial” Combination of genetic and

environmental factors Family history of disruptive behavior

disorders, mood disorders, ASPD or substance abuse– Increased rates of ODD with maternal

depression

ODD -- Etiology

Parenting style (permissive, inconsistent discipline, unavailable)

Harsh inconsistent neglectful child rearing practices

Multiple successive caregivers Family and marital discord

ODD -- Management

Few controlled studies Variety of options

– behavior therapy– family therapy– parent management training

Treat comorbidities (i.e.. ADHD)

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

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

destruction of property

Has deliberately engaged in fire setting with the intention of causing serious damage

Has deliberately destroyed others’ property

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

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

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

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

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

CD -- Subtypes

Adolescent-Onset (cont’d)– less frequently see ODD, hyperactivity and

school failure – more likely to be related to peer activities– limited to adolescence -- rarely continues

into adulthood– seldom see onset after 16 years of age

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

Factors for Poor Prognosis

Parental rejection and neglect Difficult infant temperament Inconsistent child-rearing practices with harsh

discipline Physical or sexual abuse Lack of supervision Early institutional living Frequent changes of caregivers Large family size

Factors for Poor Prognosis (cont’d)

Childhood-onset CD Comorbid ADHD High level of aggression Low intelligence Early court involvement Peer rejection Substance abuse

CD -- Epidemiology

CD is one of the most frequently diagnosed conditions in mental health facilities

prevalence – 2 to 10 %– boys 6 to 16%– girls 2 to 9%

peak age of onset is 9 y.o. seldom see onset after 16 y.o.

CD -- Etiology

Multifactorial 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

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

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

Antisocial Personality Disorder

At least 18 years of age Evidence of CD, with onset before age

15 years Not due to Schizophrenia or Mania

CD -- Course

< 50% of CD have severe and persistent antisocial problems as adults

CD – Protective Factors

easy temperament above average intelligence competence at a skill a good relationship with at least 2

caregiving adult

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

CD -- Management

Pharmacological– to treat comorbid conditions

• ADHD - stimulants, clonidine• Depression - SSRIs• Anxiety - SSRIs, Buspirone

– to treat CD alone• Impulsivity/Aggression - mood stabilizers,

neuroleptics• Hyperactivity - stimulants, clonidine

Enuresis and Encopresis

Clare Gray MD FRCPC

April 24, 2008

Enuresis and Encopresis

Enuresis– repeated voiding of urine into bed or

clothes– frequency of twice a week for 3

consecutive months or impairment in functioning

– at least 5 years old– not due to substance or medical condition

Enuresis

Nocturnal only Diurnal only Nocturnal/Diurnal Prevalence

– 7-10% boys, 3% girls– 4:1 male:female ratio– approx. 3% of boys and 2% of girls have

problems at age 10

Enuresis

Parents may see a child’s failure to toilet train as a reflection of their inadequacy as parents

symptoms become a closely guarded secret

anger, frustration and anxiety can occur parents may become harsh and punitive

Enuresis

Physiological causes– Urologic conditions

• infection, obstruction

– Anatomic abnormalities• congenital anomalies, weak bladder

– Neurologic disorders• seizures, MR, spinal cord disease

– Metabolic disorders• diabetes

Enuresis

Functional enuresis– stress, trauma, psychological crisis– 50% have comorbid emotional and

behavioural symptoms– revenge, regression, lack of training

Primary enuresis vs Secondary enuresis

Enuresis

Treatment– wait for spontaneous resolution

• 15% per year

– Behavioural treatment• bladder training exercises, alarms• restricting nighttime fluid intake, awakenings for

toilet use, star charting

– Medications• Imipramine (“gold standard”), DDAVP

Encopresis

Repeated passage of feces into inappropriate places

one event a month for 3 months chronological age of at least 4 years not due to substance or medical

condition except through a mechanism involving constipation

Encopresis

Embarrassing and stigmatizing condition

can be either primary or secondary (50 to 60%)

by age 4, approx 95% of children have attained bowel continence

prevalence– 0.3 to 8% with male:female 4:1

Encopresis

Punitive and coercive toilet training can create stress and anxiety -- toilet phobia

other life stressors (birth of sibling) early toilet training

Encopresis

Treatment– Behavioural

• consistent motivation and interest• praise• make the bathroom a pleasant and

nonthreatening place• star charts, rewarding appropriate behaviours

– Medications• treat constipation -- diet, laxatives etc