PSYC4080 6.0D ADHD and Conduct Disorders 1 Externalizing Disorders of Childhood ADHD and Conduct Disorders

PSYC4080 6.0DPSYC4080 6.0D ADHD and Conduct DisordersADHD and Conduct Disorders 11

Externalizing Disorders Externalizing Disorders of Childhoodof Childhood

ADHD and Conduct DisordersADHD and Conduct Disorders


Externalizing DisordersExternalizing Disorders

Disorders involving overt breaking of Disorders involving overt breaking of rules in multiple situationsrules in multiple situations

Must show behavioural difficulties for Must show behavioural difficulties for referralreferral

More prevalent in males than femalesMore prevalent in males than females


Outline for each diseaseOutline for each disease

Prevalence/incidencePrevalence/incidence Case StudyCase Study Diagnostic CriteriaDiagnostic Criteria Etiology: causes and originsEtiology: causes and origins Neuropathology: structural and functional Neuropathology: structural and functional effects (on the brain) effects (on the brain)

Other informationOther information


Attention Deficit/Attention Deficit/Hyperactivity Disorder (ADHD)Hyperactivity Disorder (ADHD)

PrevalencePrevalence Common childhood disorderCommon childhood disorder More prevalent in males than females (3:1)More prevalent in males than females (3:1) Prevalence: 3-5% of all school-aged Prevalence: 3-5% of all school-aged childrenchildren

Stable developmental course - 50-60% of Stable developmental course - 50-60% of all cases are noted by age 2-3 yearsall cases are noted by age 2-3 years

Majority of cases not referred until Majority of cases not referred until school age for behavioural reasonsschool age for behavioural reasons


Case StudyCase Study

““David” was a six year old, third grade student David” was a six year old, third grade student Reading and math skills one to two years below grade Reading and math skills one to two years below grade

level. level. He was failing every subject and seemed destined to He was failing every subject and seemed destined to

repeat a grade.repeat a grade. His teachers described him as disruptive and His teachers described him as disruptive and

oppositional in classoppositional in class Has difficulty paying attention during structured and Has difficulty paying attention during structured and

unstructured activities. unstructured activities.



At home David was rebellious. At home David was rebellious. His father had abandoned him virtually from birth. His father had abandoned him virtually from birth. His mother, overwhelmed by the task of raising him and His mother, overwhelmed by the task of raising him and

his two sisters without espousal help, relapsed into drug his two sisters without espousal help, relapsed into drug and alcohol abuse.and alcohol abuse.

She was frequently drunk and around David, she was She was frequently drunk and around David, she was moody and volatile. moody and volatile.

He ran wild. going to bed late at night and failing to rise He ran wild. going to bed late at night and failing to rise for school in the morning. for school in the morning.

Intermittently he wet the bed.Intermittently he wet the bed.



During the assessment: During the assessment: David could only sit for a minute. David could only sit for a minute. David described himself as dumb, but cool. David described himself as dumb, but cool. He hung out with older, rebellious students like himself to He hung out with older, rebellious students like himself to

compensate for his feelings of inadequacy. compensate for his feelings of inadequacy. He loved his mother but was struggling to maintain a He loved his mother but was struggling to maintain a

relationship with her. He hated his father and wanted relationship with her. He hated his father and wanted nothing to do with him. With his grandparents he had a nothing to do with him. With his grandparents he had a solid and positive relationship, and he especially solid and positive relationship, and he especially respected his grandfather.respected his grandfather.


DSM-IV criteriaDSM-IV criteria

A. Either:A. Either:

1.1. symptoms of symptoms of inattentioninattention that have that have persisted for at least 6 monthspersisted for at least 6 months

2.2. symptoms of symptoms of hyperactivity-impulsivityhyperactivity-impulsivity that have persisted for at least 6 months that have persisted for at least 6 months

• degree that is maladaptive and degree that is maladaptive and inconsistent with developmental level.inconsistent with developmental level.


DSM-IV criteriaDSM-IV criteria

B. Some hyperactive-impulsive or inattentive B. Some hyperactive-impulsive or inattentive symptoms are present before 7 years of symptoms are present before 7 years of age.age.

C. Impairment is present in two or more C. Impairment is present in two or more settings.settings.

D. Clear evidence of impairment in social, D. Clear evidence of impairment in social, academic, or occupational functioning.academic, or occupational functioning.


Types of ADHDTypes of ADHD

1.1. Combined typeCombined type: if both criteria attention : if both criteria attention and hyperactivity/impulsivity criteria and hyperactivity/impulsivity criteria are met.are met.

2.2. Inattentive typeInattentive type: attention criteria : attention criteria only.only.

3.3. Hyperactive–impulsive typeHyperactive–impulsive type: : hyperactive/impulsive criteria only. hyperactive/impulsive criteria only.


EtiologyEtiology

1. Genetic factors: higher risk if a parent 1. Genetic factors: higher risk if a parent has the disease. has the disease.

Dopamine transporter gene (DAT1) for Dopamine transporter gene (DAT1) for combined typecombined type

Dopamine receptor (D4) in females with Dopamine receptor (D4) in females with combined typecombined type


EtiologyEtiology

2. Systemic, organic brain damage2. Systemic, organic brain damage Hyperactivity due to brain damage caused Hyperactivity due to brain damage caused by lack of oxygen at birth (Tredgold, by lack of oxygen at birth (Tredgold, 1908).1908).

Flu and encephalitis epidemics of 1918: Flu and encephalitis epidemics of 1918: Children later showed hyperactivity, Children later showed hyperactivity, distractibility, irritability, distractibility, irritability, deceptiveness, and were unmanageable in deceptiveness, and were unmanageable in school.school.

Fetal/infant/childhood exposures: maternal Fetal/infant/childhood exposures: maternal drinking or smoking during pregnancy, drinking or smoking during pregnancy, lead, etc.lead, etc.


Other InformationOther Information

1.1. Comorbidities are commonComorbidities are common• Oppositional Defiant Disorder, Conduct Oppositional Defiant Disorder, Conduct

DisorderDisorder Poorer outcomes with comorbidity.Poorer outcomes with comorbidity.

2.2. Social difficulties Social difficulties • 50-60% experience rejection from peers50-60% experience rejection from peers immature, uncooperative, self-centred, immature, uncooperative, self-centred,

and bossy.and bossy. few close friends, and tend to play with few close friends, and tend to play with

younger children.younger children.


Other InformationOther Information

3. ADHD symptoms can persist well into 3. ADHD symptoms can persist well into adolescence and adulthood.adolescence and adulthood.

Outcome is poor particularly for Outcome is poor particularly for hyperactive-impulsive types: self-esteem, hyperactive-impulsive types: self-esteem, academic achievement, problems with the academic achievement, problems with the law.law.


NeuropathologyNeuropathology

1. Frontal lobe circuits (mesocortical)1. Frontal lobe circuits (mesocortical) Bilateral cortex, caudate and basal gangliaBilateral cortex, caudate and basal ganglia Deficit in Deficit in delaying or inhibitiondelaying or inhibition of responses, of responses,

not a perceptual or performance deficitnot a perceptual or performance deficit

2. Disruption of monoamine transmitter systems2. Disruption of monoamine transmitter systems Mesolimbic (Mesolimbic (rewardreward) pathways) pathways Based on treatment with stimulantsBased on treatment with stimulants Defective inhibitory system =increased activity Defective inhibitory system =increased activity

and less sensitivity to positive reinforcementand less sensitivity to positive reinforcement Rewards work less effectively Rewards work less effectively



3. Brain volume reduction3. Brain volume reduction Particular reduction in frontal areasParticular reduction in frontal areas Relation to response inhibition tasks (Wisconsin Relation to response inhibition tasks (Wisconsin

Card Sort)Card Sort) Relation to Relation to mesocorticalmesocortical pathways pathways


Conduct Disorder (CD)/Conduct Disorder (CD)/Oppositional Defiant Disorder (ODD)Oppositional Defiant Disorder (ODD)PrevalencePrevalence Another very common reason for referralAnother very common reason for referral CD prevalence rates in males range from 6-CD prevalence rates in males range from 6-16%; females from 2-9%. 16%; females from 2-9%.

ODD ranges from 2-16%, no gender ODD ranges from 2-16%, no gender differencesdifferences


Case StudiesCase Studies

BrandonBrandon's teachers in the daycare center 's teachers in the daycare center report that he is the "terrorist of the 4- report that he is the "terrorist of the 4- year-olds." year-olds."

He punches or bites children and pushes He punches or bites children and pushes them off the swings in the playground them off the swings in the playground without provocation. without provocation.

He swings the class pet rabbit by the tail He swings the class pet rabbit by the tail in spite of being told how it hurts the in spite of being told how it hurts the animal. animal.

His parents report that he has been His parents report that he has been difficult to manage since he was an difficult to manage since he was an infant.infant.


Case StudiesCase Studies

RobinRobin, l6: "When I was 13, that summer was , l6: "When I was 13, that summer was a blast. One time we picked up some older a blast. One time we picked up some older guys in a bar and tried a new kind of guys in a bar and tried a new kind of speed. We got really wild and we smashed speed. We got really wild and we smashed in some car windows and somebody called in some car windows and somebody called the police. My mother freaked out and the police. My mother freaked out and tried to punish me by locking me in my tried to punish me by locking me in my room, but I would just skip out on her room, but I would just skip out on her through the window."through the window."


DSM-IV Criteria for CDDSM-IV Criteria for CD

A repetitive and persistent patternA repetitive and persistent pattern Basic rights of others or major age-appropriate Basic rights of others or major age-appropriate

societal norms or rules are violatedsocietal norms or rules are violated three or more of the following criteria :three or more of the following criteria :

1. Aggression to people and animals1. Aggression to people and animals

2. Destruction of property2. Destruction of property

3. Deceitfulness or theft3. Deceitfulness or theft

4. Serious violations of rules4. Serious violations of rules

5. The disturbance in behavior causes clinically 5. The disturbance in behavior causes clinically significant impairment in social, academic, or significant impairment in social, academic, or occupational functioning.occupational functioning.


Two Types of Conduct DisorderTwo Types of Conduct Disorder

1. Childhood Onset - occurs before age 10 1. Childhood Onset - occurs before age 10 • physical aggressionphysical aggression• disturbed peer relationshipsdisturbed peer relationships• early oppositional or noncompliant behaviourearly oppositional or noncompliant behaviour

2. Adolescent-Onset - occurs after age 10 2. Adolescent-Onset - occurs after age 10 • less aggression and better peer relationsless aggression and better peer relations• poor peer group influences bad behaviourpoor peer group influences bad behaviour

Childhood Onset more likely to have a poorer Childhood Onset more likely to have a poorer prognosisprognosis


Gender: Behavioural DifferencesGender: Behavioural Differences

Boys Girls aggression lying stealing substance abuse vandalism running away firesetting sexual misconduct

(prostitution) academic problems truancy



1. XYY Syndrome in males1. XYY Syndrome in males 1:10001:1000 extra Y chromosome may lead to aggressionextra Y chromosome may lead to aggression higher rates of XYY cases in prison than in the higher rates of XYY cases in prison than in the

general population, property offenses in general population, property offenses in particular particular

Dumb criminals? Lower intelligence (lower problem Dumb criminals? Lower intelligence (lower problem solving ability) and apt to be caughtsolving ability) and apt to be caught



2. Dopamine, crime and punishment2. Dopamine, crime and punishment motivated by a pathological need for motivated by a pathological need for stimulation and reward seekingstimulation and reward seeking

less sensitive to punishment effectsless sensitive to punishment effects Overactive Behavioural Activation System Overactive Behavioural Activation System (Quay, 1988): compels them to seek rewards (Quay, 1988): compels them to seek rewards and thrillsand thrills

Underactive Behavioural Inhibition System: Underactive Behavioural Inhibition System: not as anxious or worried about not as anxious or worried about consequences consequences

Some support - Dopamine lower in frontal Some support - Dopamine lower in frontal lobes - PET (Raine, Lencz, & Scerbo, 1995). lobes - PET (Raine, Lencz, & Scerbo, 1995).


Other important informationOther important information

Difficult to treatDifficult to treat Must assure compliance before can Must assure compliance before can implement other changes.implement other changes.

Social Learning and Behavioural ApproachesSocial Learning and Behavioural Approaches Some treatment with barbiturates, Ritalin Some treatment with barbiturates, Ritalin (if ADHD is comorbid)(if ADHD is comorbid)


Oppositional Defiant DisorderOppositional Defiant Disorder

DSM-IV: if criteria for Conduct Disorder DSM-IV: if criteria for Conduct Disorder not metnot met

Pattern of defiant, angry, antagonistic, Pattern of defiant, angry, antagonistic, hostile, irritable, or vindictive behaviorhostile, irritable, or vindictive behavior

Academic outcome better for ODD than CDAcademic outcome better for ODD than CD

Documents

PSYC4080 6.0D ADHD and Conduct Disorders 1 Externalizing Disorders of Childhood ADHD and Conduct Disorders