ADHD/ODD/CD/Tic Disorders

ADHD/ODD/CD/Tic Disorders

Back to Basics

April 11, 2011

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)– Biphentin

Dextroamphetamine – Dexedrine (regular, slow release)

Adderall XR– Mixed amphetamine salts

Lisdexamfetamine (Vyvanase)– Prodrug – consists of dextroamphetamine coupled with the

essential amino acid L-lysine– converts to dextroamphetamine in the body

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

Others

Buproprion (Wellbutrin)– Atypical antidepressant– NE and DA reuptake inhibitor– Lowers seizure threshold

Atomoxetine (Strattera)– SNRI– Takes 1 to 4 weeks for effects– “24 hour” coverage

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!)• 1 - 16 %

more common in males• 2:1 males:females

onset usually by 8 years of age

Etiology – Biological Factors

Parent with DBD, mood disorder, substance abuse disorder

Maternal smoking during pregnancy Abnormalities of prefrontal cortex Altered 5HT, NA and DA

Etiology – Psychological Factors

Poor relationship with parents (insecure attachment)

Neglectful/absent parent Difficulty or inability to form social

relationships

Etiology – Social Factors

Poverty Chaotic environment (lack of structure) Lack of parental supervision Lack of positive parental involvement Inconsistent discipline Abuse/neglect

ODD -- Management

Few controlled studies Variety of options

– behavior therapy– family therapy– parent management training

Treat comorbidities (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

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

Only 3 risk factors have been shown to be “causal”– harsh, inconsistent parenting– poor academic performance– exposure to parental discord

CD -- Etiology

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


– 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


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 • Depression - SSRIs• Anxiety - SSRIs

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

neuroleptics

Tics

Part of the body moves repeatedly, quickly, suddenly and uncontrollably

Can occur in any body part, such as the face, shoulders, hands or legs

Sounds that are made involuntarily (such as throat clearing) are called vocal tics

Most tics are mild and hardly noticeable In some cases they are frequent and severe,

and can affect many areas of a child's life

Tics

5 to 24% of all school age children have had tics at some stage during this period

Tics appear to get worse with emotional stress and are absent while sleeping.

Transient Tic Disorder

The patient has vocal or motor tics,or both. They can be single or multiple.

For at least 4 weeks but no longer than 12 consecutive months, these tics have occurred many times each day, nearly every day.

These symptoms cause marked distress or materially impair work, social or personal functioning.

They begin before age 18. The symptoms are not directly caused by a general medical

condition (such as Huntington's disease or a postviral encephalitis) or to substance use (such as a CNS stimulant).

The patient has never fulfilled criteria for Tourette’s Disorder or

Chronic Motor or Vocal Tic Disorder

Chronic Tic Disorder

Single or multiple motor or vocal tics, but not both, have been present at some time during the illness.

The tics occur many times a day nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.

The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.

The onset is before age 18 years. The disturbance is not due to the direct physiological effects of a

substance or a general medical condition Criteria have never been met for Tourette’s Disorder

Tourette’s Disorder

Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently

The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.

The onset is before age 18 years. The disturbance is not due to the direct physiological

effects of a substance or a general medical condition.

Treatment

Depends on – severity, – the distress it causes to the patient– the effects the tics have on school or job

performance. Medication and psychotherapy are used

only when there is substantial interference with ordinary activities

Treatment

Neuroleptics– Pimozide– Risperidone

Other options– Clonidine

Treatment

Habit-reversal training (HRT)– Awareness training

• accentuates sensitivity to tic sensations

– Competing response training• taught a specific response pattern that would

be incompatible with the tic• replaces the tic behaviour with a more

appropriate competing response

Antares is the 15th brightest start in the sky

It is more than 1000 light years away

So just try to keep everything in perspective!!

Good Luck with the Exam!

Any questions – [email protected]

Documents

ADHD/ODD/CD/Tic Disorders