ADHD/ODD/CD/Tic Disorders

1. ADHD/ODD/CD/Tic Disorders Back to Basics April 11, 2011 Clare Gray MD FRCPC

2. Attention Deficit Hyperactivity Disorder • 3 - 7% school aged children • male:female 3-6 : 1 • Diagnostic Triad • Inattentiveness • Impulsivity • Hyperactivity

3. 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

4. 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

5. 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

6. Impulsivity Symptoms • Often blurts out answers before questions have been completed • Often has difficulty awaiting turn • Often interrupts or intrudes on others

7. 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)

8. ADHD • Types • Combined Type • Predominantly Inattentive Type • Predominantly Hyperactive/Impulsive Type • NOS

9. 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

10. ADHD • Treatment • Medication • Psychosocial treatments

11. ADHD Treatment • Medications • Stimulants • Antidepressants • Clonidine • Atypical antipsychotics

12. 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

13. Contraindications to Stimulants • Previous sensitivity to stimulants • Glaucoma • Symptomatic cardiovascular disease • Hyperthyroidism • Hypertension • MAO inhibitor • Use very carefully if history of substance abuse

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

15. Stimulants -- Side Effects • Delay of sleep onset • Reduced appetite • Weight loss • Tics • Stomach ache • Headache • Jitteriness

16. Effectiveness of Stimulants • At least 70% response rate to first stimulant tried

17. 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

18. ADHD • Psychosocial treatments • parent training • psychoeducation, behaviour management, support • school interventions • remediation, behaviour management, • individual therapy • anger management, supportive, CBT, psychoedn

19. 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

20. 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

21. 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

22. 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

23. Etiology – Biological Factors • Parent with DBD, mood disorder, substance abuse disorder • Maternal smoking during pregnancy • Abnormalities of prefrontal cortex • Altered 5HT, NA and DA

24. Etiology – Psychological Factors • Poor relationship with parents (insecure attachment) • Neglectful/absent parent • Difficulty or inability to form social relationships

25. Etiology – Social Factors • Poverty • Chaotic environment (lack of structure) • Lack of parental supervision • Lack of positive parental involvement • Inconsistent discipline • Abuse/neglect

26. ODD -- Management • Few controlled studies • Variety of options • behavior therapy • family therapy • parent management training • Treat comorbidities (ADHD)

27. 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

28. 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

29. destruction of property • Has deliberately engaged in fire setting with the intention of causing serious damage • Has deliberately destroyed others’ property

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

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

37. 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

38. 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

39. 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

40. Antisocial Personality Disorder • At least 18 years of age • Evidence of CD, with onset before age 15 years • Not due to Schizophrenia or Mania

41. CD -- Course • < 50% of CD have severe and persistent antisocial problems as adults

42. CD – Protective Factors • easy temperament • above average intelligence • competence at a skill • a good relationship with at least 2 caregiving adult

43. 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

44. CD -- Management • Pharmacological • to treat comorbid conditions • ADHD – stimulants • Depression - SSRIs • Anxiety - SSRIs • to treat CD alone • Impulsivity/Aggression - mood stabilizers, neuroleptics

45. 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

46. 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.

47. 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

48. 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

49. 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.

50. 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