Mood & Disruptive Behavior Disorders in Children & Adolescents

Dr. Bruce Michael CappoClinical Associates, P.A.

OverviewFoundation for DiagnosisDiagnostic Issues for children & adolescents

Similarities / differencesTreatment Strategies

Diagnoses

DepressionBipolar DisorderAttention Deficit Hyperactivity Disorder

Conduct Disorders

DiagnosesOppositional Defiant DisorderDisruptive Behavior DisorderAdjustment Disorder with Disturbance of Conduct

Child or Adolescent Antisocial Behavior

Pervasive Developmental Disorders

A Little History ...

Diagnostic & Statistical Manual of Mental Disorders (1952)

DSM - II (1975)DSM - III (1980)DSM - IIIR (1987)DSM - IV (1994)DSM - IV TR 2000 (2000)

Defining Mental Disorder

Clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom.

Clinical Judgement

Should NOT be employed mechanically by untrained individuals

Guidelines to facilitate informed clinical judgement

NOT to be used in a cookbook fashion

Axis I

Clinical DisordersOther conditions that may be a focus of clinical attention

Axis II

Personality Disorders

Mental Retardation

Axis III

General Medical Conditions

Axis IV

Psychosocial & Environmental Problems

Axis V

Global Assessment of Functioning

Organization

16 Major Diagnostic ClassesOther conditions that may be a focus

Focus here is on a select few of the disorders of childhood

Disorders of Infancy, Childhood & Adolescence...Mental RetardationLearning DisordersMotor Skills DisordersCommunication DisordersPervasive Developmental DisordersAttention-Deficit & Disruptive

Behaviors

Disorders of Infancy, Childhood & Adolescence

Feeding & Eating DisordersTic DisordersElimination DisordersOther Disorders of Infancy & Childhood

Additional Classifications...

Eating DisordersSleep DisordersImpulse Control DisordersAdjustment DisordersPersonality DisordersOther conditions that are a focus

of clinical attention

Trivia Snapshot

A YoYo can achieve speeds up to 11,000 rpm

Depression5 or more during a 2 week period which represents a change in function

depressed mood irritable mood in children & adolescents

markedly diminished interest in pleasure

significant weight change (5%)

Depressioninsomnia or hypersomniapsychomotor agitation or retardation nearly

dailyfatigue or loss of energy nearly dailyfeelings of worthlessness or guiltdiminished ability to concentraterecurrent thoughts of deathnot due to substance, bereavement or

medical condition

Age & Gender factors

twice as common in females than males for adults & adolescents

prepubertal males / females equally affected

Lifetime Risk Factor

10-25% for women5-12% for menPrevalence rates at a given time in community 5-9% of women 2-3% of men

Risk Factors

Genetic predisposition (especially maternal)

Avg age of onset is mid 20sOnset age decreasingPrepubertal onset may increase risk of bipolar

Suicide Risk

15% of persons with MDD die by suicide

Older adult up to 4x that riskTake statements of self harm very seriously in children

“Connectedness”

Connected to family & peers

Too much AND too little involvement is bad

Teach moderation and balance in life

Treatment

Cognitive Behavioral Therapy (CBT)

Pharmacological interventionsPlay Therapy in younger kidsFamily therapy / Involvement

CBT

Re-interpret situations and responses

Research supports effectiveness over 20 week period

Faster, not necessarily better when combined with Medication

Feeling Good by David Burns, MD

Medication

Not always necessary and not a first option in most cases

SSRIs - Serotonin reuptake inhibitors (zoloft, paxil, prozac, etc)

2-3 weeks before improvement, optimal at 4 weeks, change at 5 weeks without improvement

Other classes: tricyclics, MAOIs

Medication

Minimal side effects with SSRIs33% of adolescents take meds

as prescribed“If I take meds then there must

be something wrong with me...I don’t want anything to be wrong so I won’t take meds”

Play Therapy

Often indirectPuppets, games, role playing

Family Therapy

Systems ApproachClarify roles in familyIdentify and change dysfunction

Bipolar

I One or more manic or mixed episodes

often one or more depressive episodes

II recurrent major depressive episodes with hypomanic episodes

Manic Episodes

Elevated, expansive or irritable mood

inflated self esteem or grandiositydecreased need for sleepmore talkative, pressured speechflight of ideas

Manic Episodes

distractibilityincreased goal directed activityexcessive involvement in pleasurable activities despite adverse consequences

marked impairment

Hypomanic episode

shorter, 4 versus 7 days minimum

not as severe - need not cause marked impairment

Treatment

PharmacologicalEducate on chronic nature of disorder

Coping strategy developmentRecognize early warning signs of mood shift

Family education

MedicationLithium carbonate, Depakote,

Neurontin, Topamax, Tegretol, SSRIsCompliance is a chronic problemVery likely to discontinue meds and

have problemsTherapy to promote compliance and

understanding

Trivia Snapshot

It is actually the tomato sauce that burns your mouth when pizza is too hot - NOT the cheese

Attention Deficit Hyperactivity Disorder

ADHDADDAttention Deficit Disorder

with/without HyperactivityName has changed in DSM

through the years

PrevalencePrevalence

Estimates range from 2% - 5% of girls and from 5% - 7% of boys

Symptoms present & diagnosable by age 7

ADD Symptoms decrease with age

Comorbidity increases with age

DSM IV Criteria (summarized)DSM IV Criteria (summarized)

Inattention, impulsivity or hyperactivity

Onset before age 7Symptoms seen in at least 2

situations (home, school, etc.)Significant impairment in

functioning

Diagnostic Criteria (type)Diagnostic Criteria (type)

Attention Deficit Disorder Inattentive Type Impulsive Type Hyperactive Type Combined Type

2 5 - 3 0 %

In a tten tive H yp erac tive Im p u ls ive

7 0 - 7 5 %

C om b in ed

A tten tion D e fic it D iso rd erTyp es

InattentionInattention

Difficulty sustaining attention

Does not seem to listenMakes careless mistakesFails to complete tasks without being oppositional

Inattention

Difficulty organizing activitiesEasily BoredLoses thingsForgetfulEasily distracted

HyperactivityHyperactivity

Runs about inappropriatelyHas difficulty staying in seatFidgets or squirmsDoes not play alone quietly“Motor Driven”

ImpulsivityImpulsivity

Interrupts othersBlurts out answers in class before called on

Has difficulty awaiting his/her turn

Prevalence

Comorbidityincreaseswith age

ADDSymptomsdecreasewith age

Symptoms present & diagnosable by age 6

2 - 5 %Higher for boys than girls

Comorbidity FactorsComorbidity Factors

50% - 80% have some comorbid condition

Oppositional Defiant DisorderConduct DisorderImpaired Academic FunctioningMood DisordersTic Disorders

Oppositional Defiant DisorderOppositional Defiant Disorder

40% of children65% of adolescents

Conduct DisorderConduct Disorder

21% - 45% of children

44% - 50% of adolescents

Impaired Academic FunctioningImpaired Academic Functioning

40% in special education classes

19% - 26% with at least one learning disorder

Mood DisordersMood Disorders

15% - 20% with Depression

20% - 25% with Anxiety

Tic DisordersTic Disorders

10% with Tourette’s Syndrome

AssessmentAssessment

Detailed historyObjective assessment devicesNorm-based symptom scales for parents

Norm-based symptom scales for teachers

Clinical impressions / interview

Detailed HistoryDetailed History

Early growth & development

Social Behavior Academic functioning Family functioning

Objective Assessment DevicesObjective Assessment Devices

Continuous Performance Tests (CPT)

Intelligence Tests Achievement Tests

Norm-based symptom scales for parents & teachersNorm-based symptom scales for parents & teachers

ConnersAuffenbachBrownYale & Many Others

TreatmentTreatment

Parent TrainingSocial Skills TrainingEducational ConsultationPsychopharmacologic Treatment

Non-Medication InterventionsNon-Medication InterventionsControl Setting Variables Control Task VariablesToken SystemSelf-MonitoringContracting

Pharmacologic Interventions

StimulantsSSRIsAntihypertensivesAnticonvulsants

Commonly Prescribed StimulantsCommonly Prescribed StimulantsRitalin (methylphenidate)Dexedrine (dextroamphetamine)Adderall (amphetamine mixed salts)Concerta (methylphenidate)Metadate (methylphenidate)Out of favor - Cylert (pemoline) There is poor correspondence between

clinical effects & blood levelsTest / Re-Test Paradigm better than

mg/kg body weight dosing

Ritalin (methylphenidate)Ritalin (methylphenidate)

Around over 50 years 5 mg to 60 mg per day in divided doses Mixed experience with sustained release but may work well in combination with non-SR

Onset 15-30 minutes; Peak 90 minutes; lasts 4-6 hours

New product on the way with 12 hour dosing

Adderall

6-8 hoursGood choice for younger kids without homework

Most get by with once a day dosing

Concerta

18 mg & 36 mg12 hoursOnce daily dosingMust take capsule wholemore expensive

Metadate

10 hours30% fast actng70% slow actingLess expensiveCan be sprinkled on food

Other Classes of Medications UsedOther Classes of Medications UsedAntidepressants

Tofranil (imipramine) Wellbutrin (buproprion) Prozac (fluoxetine) Zoloft Often in combination with Ritalin

Other Classes of Medications Used

Blood Pressure Meds Tenex (guanfacine) Catapres (clonidine)

Others less used Buspar (buspirone) Lithium Carbonate

Treatment using a multi-modal approach

parent trainingbehavior managementenvironment management

classroom interventions

Summary

Assess & diagnose properlyMedication is a primary intervention

Multi-modal approach is preferred to meds only

Trivia Snapshot

When you watch a baseball game on TV you actually hear the crack of the bat sooner than the fans at the game because of the placement of the microphone and the speed of sound versus the speed of the electrical transmissions used for broadcasting the signal

Conduct DisordersRepetitive pattern of behavior

in which the basic rights of others or major societal norms/rules are violated

Clinically significant impairment in social, academic or occupational functioning

Conduct Disorders3 or more in past 12 months

aggression to people or animals

destruction of property deceitfulness or theft serious violations of rules

Prevalence

Elementary - 2% girls, 7% boysMiddle - 2-10% girls, 3-16% boys

High School - 4-15% boys & girls

Higher in urban than rural

Looking Ahead

50% of those showing Sx in elementary school continue to do so during adolescence

40-75% of adolescents continue Sx as adults

High Risk Signs

ADHDEarly onset before age 10 (most

important)Multiple types of antisocial behaviors

stealing, lying, fightingHigh frequency of acting outBehaviors displayed in multiple settings

school, home, community

Comorbidity

21% Major Depression or Bipolar Disorder

24% Anxiety Disorder31% ADHD

Treatment

Behavior TherapyCognitive TherapyFamily TherapyGroup TherapyPsychodynamic or Interpersonal Therapy

Behavior Therapy

Parent trainingSchool based management programs

Token SystemsReinforce desired behaviors through multiple settings

Cognitive Therapy

Changing ineffective thought processes

Consider potential and actual consequences of behavior

Connect choices with outcomesConsider potential and actual consequences of behavior

Cognitive Therapy

Connect choices with outcomesProblem solving techniquesSocial Processing Deficits

misinterpret situations base response on misinterpretationsevent - anger - run away

Family Therapy

Changing family communication processes

Identify and change dysfunctional systems

Clarify roles

Group Therapy

Facilitate contact with prosocial peers in structured setting

“old guy in a tie” vs “experts”Confrontation by peersMixed groups with experienced leaders did best

Psychodynamic / Interpersonal Therapy

Attachment theoryImprove relationship with parent and others

Less research support

EffectivenessDecreased Sx shown after 3-4 months of

TxSome did well at 1 year follow-upSome do not maintain Tx gainsLowered recidivism rates 6 - 18 months outNumber of serious criminal offenses stayed

the same These may be more difficult cases May require higher level of treatment

Oppositional Defiant Disorder

Pattern of negativistic, hostile & deviant behavior lasting at least 6 months during which 4 are present often loses temper argues with adults actively defies requests or rules

Oppositional Defiant Disorder

blames others for his misbehaviors

easily annoyed by others angry & resentful spiteful & vindictive

Oppositional Defiant Disorder

There is clinically significant impairment in social, academic or occupational functioning

not specific to a psychotic or mood disorder

does not meet criteria for conduct disorder

Disruptive Behavior Disorder

Ongoing pattern of CD & ODD behaviors that fail to meet criteria for full diagnosis

Adjustment Disorder with Disturbance of Conduct

Can be with Mixed Emotional Features also

Occurs within 3 months of identifiable stressor

Can include mood swings

Child or Adolescent Antisocial Behavior

Isolated antisocial behaviors not considered indicative of a mental disorder

i.e. shoplifting but no other problems

Pervasive Developmental Disorders

Severe & pervasive impairment in several areas of development

Reciprocal social interactions skillsCommunication skillsStereotyped behaviors, interests,

activitiesDeviant to developmental level or age

Pervasive Developmental Disorders

Autistic disorderRett’s disorderChildhood disintegrative disorder

Asperger’s disorderPDD NOS

Autistic Disorder CriteriaQualitative impairment in social interactionMarked impairment in nonverbal behaviors

eye contact, facial expressions, gesturesFailure to develop peer relationshipsLack of spontaneously seeking to share

enjoymentLack of emotional reciprocity

Autistic Disorder CriteriaDelay / Lack of developed spoken language

When speech present - not initiate or sustain conversations

Idiosyncratic languageLack of varied spontaneous play

Autistic Disorder CriteriaRestricted, stereotyped patterns of behavior

Inflexible adherence to ritualsRepetitive motor mannerismsPreoccupation with parts of objects

Rett’s Disorder

Distinctive regression of abilities and slowed head growth

Only femalesLess frequent than Autism

Rett’s Disorder Criteria

Normal prenatal & perinatal development

Normal development first 5 months

Normal head circumference at birth

Rett’s Disorder CriteriaDecelerated head growth 5 - 48 months

Loss of previously acquired skills Development of steretyped hand movements

Loss of social engagemenetPoor coordinationImpaired language

Asperger’s DisorderNo mental retardation which may be present in Autistic disorder

Mild level of delay symptomsGood verbal skills usuallyFrequently seen with ADHD & depressive disorders

Asperger’s DisorderIncreased interest in social relationships but impaired ability

May duplicate routines or rules without understanding

Frequent behavior problems in adolescence

Usually the one caught when numerous kids involved

Types of Social Behavior Dysfunction

Key defining feature of autismCan be classified into three categories: socially avoidant socially indifferent socially awkward.

Socially AvoidantAvoid virtually all forms of social interaction

Tantrum and/or 'run away' when someone tries to interact with him/her

As infants, some are described as 'arching their back' from a caregiver to avoid contact

Socially IndifferentDon’t seek social interaction with

others (unless they want something)Don’t actively avoid social situationsDon’t seem to mind being with peopleDon’t mind being by themselvesCommon in the majority of autistic

individuals

Socially IndifferentOne theory is that autistic individuals do not obtain

'biochemical' pleasure from being with people. Research by Professor Jaak Panksepp at Bowling Green State University in Ohio has shown that beta-endorphins, an endogenous opiate-like substance in the brain, is released in animals during social behavior. Additionally, there is evidence that the beta-endorphin levels in autistic individuals is elevated so they do not need to rely on social interaction for pleasure. Some research on the drug, naltrexone, which blocks the action of beta-endorphins, has shown to increase social behavior.

Socially AwkwardTry very hard to have friends, but cannot keep

themCommon to Asperger SyndromeLack reciprocity in their interactionsConversations often revolve around themselves &

are self-centeredThey don’t learn social skills and social taboos by

observing othersLack common sense when making social decisions

Treatment

Sensory BasedBioMedicalSocial

Sensory

If the problem appears to be due to hypersensitivity to sensory stimuli, sensory-based interventions may be helpful, such as auditory integration training, sensory integration & visual training. Another strategy would be to remove these sensory intrusions from the person's environment.

Biomedical

Naltrexone is usually not prescribed to improve social interaction; however, research studies and parent reports have indicated improved social skills when given Vitamin B6 and magnesium, and/or dimethylglycine (DMG) Research is mixed on this. Lots of anecdotal stories on internet

Social

A treatment strategy to improve social behavior is using 'social stories'. This involves presenting short stories to teach socially appropriate behaviors. These stories are used to teach the individual to understand the behavior of themselves and others better.

Time For Your Questions