Externalizing Disorders of Childhood

1. Externalizing Disorders of Childhood ADHD and Conduct Disorders ADHD and Conduct Disorders

2. Externalizing Disorders • Disorders involving overt breaking of rules in multiple situations • Must show behavioural difficulties for referral • More prevalent in males than females ADHD and Conduct Disorders

3. Outline for each disease • Prevalence/incidence • Case Study • Diagnostic Criteria • Etiology: causes and origins • Neuropathology: structural and functional effects (on the brain) • Other information ADHD and Conduct Disorders

4. Attention Deficit/Hyperactivity Disorder (ADHD) Prevalence • Common childhood disorder • More prevalent in males than females (3:1) • Prevalence: 3-5% of all school-aged children • Stable developmental course - 50-60% of all cases are noted by age 2-3 years • Majority of cases not referred until school age for behavioural reasons ADHD and Conduct Disorders

5. Case Study • “David” was a six year old, third grade student • Reading and math skills one to two years below grade level. • He was failing every subject and seemed destined to repeat a grade. • His teachers described him as disruptive and oppositional in class • Has difficulty paying attention during structured and unstructured activities. ADHD and Conduct Disorders

6. Case Study • At home David was rebellious. • His father had abandoned him virtually from birth. • His mother, overwhelmed by the task of raising him and his two sisters without espousal help, relapsed into drug and alcohol abuse. • She was frequently drunk and around David, she was moody and volatile. • He ran wild. going to bed late at night and failing to rise for school in the morning. • Intermittently he wet the bed. ADHD and Conduct Disorders

7. Case Study During the assessment: • David could only sit for a minute. • David described himself as dumb, but cool. • He hung out with older, rebellious students like himself to compensate for his feelings of inadequacy. • He loved his mother but was struggling to maintain a relationship with her. He hated his father and wanted nothing to do with him. With his grandparents he had a solid and positive relationship, and he especially respected his grandfather. ADHD and Conduct Disorders

8. DSM-IV criteria A. Either: • symptoms of inattention that have persisted for at least 6 months • symptoms of hyperactivity-impulsivity that have persisted for at least 6 months • degree that is maladaptive and inconsistent with developmental level. ADHD and Conduct Disorders

9. DSM-IV criteria B. Some hyperactive-impulsive or inattentive symptoms are present before 7 years of age. C. Impairment is present in two or more settings. D. Clear evidence of impairment in social, academic, or occupational functioning. ADHD and Conduct Disorders

10. Types of ADHD • Combined type: if both criteria attention and hyperactivity/impulsivity criteria are met. • Inattentive type: attention criteria only. • Hyperactive–impulsive type: hyperactive/impulsive criteria only. ADHD and Conduct Disorders

11. Etiology 1. Genetic factors: higher risk if a parent has the disease. • Dopamine transporter gene (DAT1) for combined type • Dopamine receptor (D4) in females with combined type ADHD and Conduct Disorders

12. Etiology 2. Systemic, organic brain damage • Hyperactivity due to brain damage caused by lack of oxygen at birth (Tredgold, 1908). • Flu and encephalitis epidemics of 1918: Children later showed hyperactivity, distractibility, irritability, deceptiveness, and were unmanageable in school. • Fetal/infant/childhood exposures: maternal drinking or smoking during pregnancy, lead, etc. ADHD and Conduct Disorders

13. Other Information • Comorbidities are common • Oppositional Defiant Disorder, Conduct Disorder • Poorer outcomes with comorbidity. • Social difficulties • 50-60% experience rejection from peers • immature, uncooperative, self-centred, and bossy. • few close friends, and tend to play with younger children. ADHD and Conduct Disorders

14. Other Information 3. ADHD symptoms can persist well into adolescence and adulthood. • Outcome is poor particularly for hyperactive-impulsive types: self-esteem, academic achievement, problems with the law. ADHD and Conduct Disorders

15. Neuropathology 1. Frontal lobe circuits (mesocortical) • Bilateral cortex, caudate and basal ganglia • Deficit in delaying or inhibition of responses, not a perceptual or performance deficit 2. Disruption of monoamine transmitter systems • Mesolimbic (reward) pathways • Based on treatment with stimulants • Defective inhibitory system =increased activity and less sensitivity to positive reinforcement • Rewards work less effectively ADHD and Conduct Disorders

16. Neuropathology 3. Brain volume reduction • Particular reduction in frontal areas • Relation to response inhibition tasks (Wisconsin Card Sort) • Relation to mesocortical pathways ADHD and Conduct Disorders

17. Conduct Disorder (CD)/Oppositional Defiant Disorder (ODD) Prevalence • Another very common reason for referral • CD prevalence rates in males range from 6-16%; females from 2-9%. • ODD ranges from 2-16%, no gender differences ADHD and Conduct Disorders

18. Case Studies • Brandon's teachers in the daycare center report that he is the "terrorist of the 4- year-olds." • He punches or bites children and pushes them off the swings in the playground without provocation. • He swings the class pet rabbit by the tail in spite of being told how it hurts the animal. • His parents report that he has been difficult to manage since he was an infant. ADHD and Conduct Disorders

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

20. DSM-IV Criteria for CD • A repetitive and persistent pattern • Basic rights of others or major age-appropriate societal norms or rules are violated • three or more of the following criteria : 1. Aggression to people and animals 2. Destruction of property 3. Deceitfulness or theft 4. Serious violations of rules 5. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. ADHD and Conduct Disorders

21. Two Types of Conduct Disorder 1. Childhood Onset - occurs before age 10 • physical aggression • disturbed peer relationships • early oppositional or noncompliant behaviour 2. Adolescent-Onset - occurs after age 10 • less aggression and better peer relations • poor peer group influences bad behaviour • Childhood Onset more likely to have a poorer prognosis ADHD and Conduct Disorders

22. Gender: Behavioural Differences ADHD and Conduct Disorders

23. Neuropathology 1. XYY Syndrome in males • 1:1000 • extra Y chromosome may lead to aggression • higher rates of XYY cases in prison than in the general population, property offenses in particular • Dumb criminals? Lower intelligence (lower problem solving ability) and apt to be caught ADHD and Conduct Disorders

24. Neuropathology 2. Dopamine, crime and punishment • motivated by a pathological need for stimulation and reward seeking • less sensitive to punishment effects • Overactive Behavioural Activation System (Quay, 1988): compels them to seek rewards and thrills • Underactive Behavioural Inhibition System: not as anxious or worried about consequences • Some support - Dopamine lower in frontal lobes - PET (Raine, Lencz, & Scerbo, 1995). ADHD and Conduct Disorders

25. Other important information • Difficult to treat • Must assure compliance before can implement other changes. • Social Learning and Behavioural Approaches • Some treatment with barbiturates, Ritalin (if ADHD is comorbid) ADHD and Conduct Disorders

26. Oppositional Defiant Disorder • DSM-IV: if criteria for Conduct Disorder not met • Pattern of defiant, angry, antagonistic, hostile, irritable, or vindictive behavior • Academic outcome better for ODD than CD ADHD and Conduct Disorders