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ADHD/ODD/CD
Back to Basics
April 24, 2008
Clare Gray MD FRCPC
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Attention Deficit Hyperactivity Disorder 3 - 7% school aged children male:female 3-6 : 1 Diagnostic Triad
– Inattentiveness– Impulsivity– Hyperactivity
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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
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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
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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
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Impulsivity Symptoms
Often blurts out answers before questions have been completed
Often has difficulty awaiting turn Often interrupts or intrudes on others
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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)
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ADHD
Types– Combined Type– Predominantly Inattentive Type– Predominantly Hyperactive/Impulsive Type– NOS
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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
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ADHD
Treatment– Medication– Psychosocial treatments
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ADHD Treatment
Medications– Stimulants– Antidepressants– Clonidine– Atypical antipsychotics
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Stimulants
Methylphenidate – Ritalin (regular, slow release)– OROS Methylphenidate (Concerta)
Dextroamphetamine – Dexedrine (regular, slow release)
Adderrall XR– Mixed amphetamine salts
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Contraindications to Stimulants
Previous sensitivity to stimulants Glaucoma Symptomatic cardiovascular disease Hyperthyroidism Hypertension MAO inhibitor Use very carefully if history of substance
abuse
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Stimulants
Monitor Carefully if:– Motor tics– Marked anxiety– Tourette’s syndrome– Seizures– Very young (3-6 year olds)
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Stimulants -- Side Effects
Delay of sleep onset Reduced appetite Weight loss Tics Stomach ache Headache Jitteriness
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Effectiveness of Stimulants
At least 70% response rate to first stimulant tried– Fewer than half show total normalization
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Others
Buproprion (Wellbutrin) Atomoxetine (Strattera)
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ADHD
Psychosocial treatments– parent training
• psychoeducation, behaviour management, support
– school interventions• remediation, behaviour management,
– individual therapy • anger management, supportive, CBT,
psychoedn
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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
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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
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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
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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
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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
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ODD -- Etiology
Parenting style (permissive, inconsistent discipline, unavailable)
Harsh inconsistent neglectful child rearing practices
Multiple successive caregivers Family and marital discord
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ODD -- Management
Few controlled studies Variety of options
– behavior therapy– family therapy– parent management training
Treat comorbidities (i.e.. ADHD)
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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
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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
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destruction of property
Has deliberately engaged in fire setting with the intention of causing serious damage
Has deliberately destroyed others’ property
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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
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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
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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
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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
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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
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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
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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
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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
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Factors for Poor Prognosis (cont’d)
Childhood-onset CD Comorbid ADHD High level of aggression Low intelligence Early court involvement Peer rejection Substance abuse
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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.
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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
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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
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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
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Antisocial Personality Disorder
At least 18 years of age Evidence of CD, with onset before age
15 years Not due to Schizophrenia or Mania
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CD -- Course
< 50% of CD have severe and persistent antisocial problems as adults
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CD – Protective Factors
easy temperament above average intelligence competence at a skill a good relationship with at least 2
caregiving adult
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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
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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
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Enuresis and Encopresis
Clare Gray MD FRCPC
April 24, 2008
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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
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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
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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
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Enuresis
Physiological causes– Urologic conditions
• infection, obstruction
– Anatomic abnormalities• congenital anomalies, weak bladder
– Neurologic disorders• seizures, MR, spinal cord disease
– Metabolic disorders• diabetes
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Enuresis
Functional enuresis– stress, trauma, psychological crisis– 50% have comorbid emotional and
behavioural symptoms– revenge, regression, lack of training
Primary enuresis vs Secondary enuresis
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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
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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
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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
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Encopresis
Punitive and coercive toilet training can create stress and anxiety -- toilet phobia
other life stressors (birth of sibling) early toilet training
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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