Transcript Externalizing Disorders of Childhood

Externalizing Disorders
of Childhood
ADHD and Conduct Disorders
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Externalizing Disorders
 Disorders involving overt breaking of rules in
multiple situations
 Must show behavioural difficulties for referral
 More prevalent in males than females
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Outline for each disease
Prevalence/incidence
Case Study
Diagnostic Criteria
Etiology: causes and origins
Neuropathology: structural and functional effects
(on the brain)
 Other information
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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
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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.
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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.
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Case Study
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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.
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DSM-IV criteria
A. Either:
1. symptoms of inattention that have persisted
for at least 6 months
2. symptoms of hyperactivity-impulsivity that
have persisted for at least 6 months
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degree that is maladaptive and inconsistent with
developmental level.
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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.
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Types of ADHD
1. Combined type: if both criteria attention and
hyperactivity/impulsivity criteria are met.
2. Inattentive type: attention criteria only.
3. Hyperactive–impulsive type:
hyperactive/impulsive criteria only.
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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
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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.
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Other Information
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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.
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Other Information
3. ADHD symptoms can persist well into
adolescence and adulthood.
 Outcome is poor particularly for hyperactiveimpulsive types: self-esteem, academic
achievement, problems with the law.
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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
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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
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Neuropathology
3.
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Brain volume reduction
Particular reduction in frontal areas
Relation to response inhibition tasks (Wisconsin Card Sort)
Relation to mesocortical pathways
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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
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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.
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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."
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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 :
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Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violations of rules
The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational functioning.
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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
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Gender: Behavioural Differences
Boys
Girls
aggression
lying
stealing
substance abuse
vandalism
running away
firesetting
sexual misconduct
(prostitution)
truancy
academic problems
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Neuropathology
1.
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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
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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).
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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)
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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
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