Transcript H382 The Problems Kids Have

H382 THE
CHALLENGES KIDS
FACE
ADHD and Other
Behavioral Challenges
Holly Lem, Ph.D.
November 13, 2015
THE “BAD SEED”/WE NEED TO TALK
ABOUT KEVIN
 http://www.youtube.com/watch?v=wxisjomvvSY
“DISRUPTIVE” BEHAVIORAL
DISORDERS DEMAND OUR
ATTENTION
Annual costs to society: estimated billions of
dollars (Jensen et al., 2005)
Criminal behavior and delinquency
Substance abuse
Risk taking behaviors that jeopardize self and
others
Teen pregnancy
NOT ALL AGGRESSION IS EQUAL(FRICK,
1993)
• Covert/
• Destructive
• Covert/
• Nondestructive
• Overt/
• Destructive
Violations
of
Property:
Theft,
vandalism
Fire setting
Violations
of Status:
truancy,
running
away, rule
violations
Aggressive
behaviors,
bullies,
fights,
cruel,
blaming
Stubborn,
Arguing,
defiant,
challenging
• Overt/
• Nondestructive
RELATIONAL AGGRESSION (CRICK &
GROTPETER, 1995)
“…involves harming others
through purposeful manipulation
and damage of their peer
relationships.”
A SPECTRUM OF DIFFICULTIES?
 ADHD: A persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with functioning or
development
 Oppositional Defiant Disorder (ODD): A pattern of
angry/irritable mood, argumentative/defiant behavior or
vindictiveness lasting as least 6 months
 Conduct Disorder (CD): A repetitive and persistent pattern
in which basic rights of others… or age appropriate
norms/rules are violated(e.g., aggression to people/animals,
destruction of property, theft, serious violation of rules)
OPPOSITIONAL DEFIANT DISORDER
(DSM-5)
 A pattern of angry/irritable mood, argumentative/defiant behavior
or vindictiveness at least 6 months… 4 symptoms from the
following….shown during interaction with one individual who is
not sibling
 Angry/irritable Mood (loses temper, easily annoyed,
angry/resentful)
 Argumentative/Defiant Behavior (argues with authority
figures, actively defies or refused to comply with requests from
authority figures; deliberately annoys others; blames others for
misbehaviors)
 Vindictiveness (vindictive or spiteful at least twice in 6 mos)
ODD
 Over 5, symptomatic once a week for 6 mos.
 Prevalence: between 1-11% , average estimate of 3.3%
 Typical onset between 4-8 years old
 More prevalent in males than females prior to
adolescence (1.4:1)
 Comorbidity: ADHD, CD, Anxiety, Mood
 Variant of CD? Less severe form? Look at mood &
behavior symptoms
 75% don’t develop CD
CONDUCT DISORDER
(DSM-5)
 A repetitive and persistent pattern of behavior which violates the
rights of others or age-appropriate societal norms… at least three of the
following in the last 12 mos.
 Aggression to People/animals: (bullies, threatens, intimidates
others, fights, uses weapons to hurt; physically cruel to animals/people,
stolen, forced sexual activity)
 Destruction of property: (fire setting, deliberately destroyed
property)
 Deceitfulness/theft: (broken into someone’s house, car, cons
others, stolen non trivial items)
Serious violation of rules:
(stayed out all night, run away
from home at least twice, truant from school)
CONDUCT DISORDER
Childhood Onset: more severe/worrisome
1. One symptom before the age of 10
2. Frequently male
3. Displays physical aggression toward others
4. Usually concurrent ADHD, previous ODD***
5. Persists into adulthood
6. Specify: limited prosocial emotions, lack of remorse,
callous-lack of empathy
7. Usually family hx sign for psychopathology, abuse, neglect,
coercive parenting, substance abusing, criminality
HOSTILE ATTRIBUTION BIAS AND CD
Tendency to interpret ambiguous actions or
expressions as having a hostile intent and then
responding to the perception as a threat with…
VIOLENCE, AGGRESSION, HOSTILITY
Why is the world such a hostile place?
What can you do it about it?
CAN YOU CALL A 9-YEAR-OLD A
PSYCHOPATH?” (NEW YORK TIMES, MAY 11, 2012)
“While queuing up a Pokeman video on
the family’s computer upstairs, Michael
turned to me and remarked crisply, “As
you can see I don’t really like Allan.., yes,
it’s true… I hate him.”
INVENTORY OF
CALLOUS-UNEMOTIONAL (ICU) FRICK,
2004
 Lack of empathy
 Lack of guilty
 Constricted emotion/shallow/deficient emotion
 Cold, Uncaring
 With CD: proactive aggression, low sensitivity to
punishment, sensation seeking, poor response to
treatment
 Very stable traits
 http://psyc.uno.edu/Frick%20Lab/ICU.html
ETIOLOGY OF DISRUPTIVE BEHAVIORAL
DISORDERS: DEVELOPMENTAL
PERSPECTIVE (CONDUCT PROBLEMS PREVENTION
RESEARCH GROUP, 2011)
Difficult
Temperament
Overwhelmed
parents; few
resources
Child poorly
prepared coping,
social skills
THE FAST TRACK PREVENTION
INTERVENTION (CPPRG, 2011)
 4 Universities involved (Duke,Vanderbilt, Washington, Penn)
 891 children
 4 geographical sites
 Multi-gating screening: top 40% chosen
 Two Phase Intervention:
 Elementary (grades 1-5): parent training, teacher training, home
visits, social skills training, tutoring, peer groups
 Middle/high school: transition group, parenting groups, youth
groups
 Results: reduced the likelihood by half that kids would get CD dx
ALL BRAINS ARE UNIQUE: ESSENTIAL
CHECKLIST FOR THOSE WORKING WITH KIDS WITH ADHD
(NOWELL, 2007)
 Fun to be around
Makes me laugh
 Enthusiastic
Takes risk
 Spontaneous
Brave
 Creative
Makes me feel like a kid
 High energy
 Has good intuition
 Curious
 Thinks quickly
Sees things differently
ADHD: A MORAL DEFECT?
“For some years past I have been collecting
observations with a view to investigating the
occurrence of defective moral control as a morbid
condition in children, a subject I cannot but think
calls urgently for scientific investigation.” (Still,
1902)
ADHD HISTORICAL CONTEXT
1902 Lecture Royal College of Physicians
(aggressive, poorly inhibited, excessively active, poor
sustained attention)
35 year gap World Wars
Encephalitis Epidemic: ADHD like symptoms
Minimal Brain Damage/Brain Dysfunction
(40’s – 70’s)– excessive motor activity
Hyperkinetic Reaction of Childhood ( 60’s -70’s)
AD(H)D & THE DSM
 Identity Crisis
 How essential is hyperactivity to the diagnosis?
 DSM-III (1980) ADD with/without hyperactivity
 DSM- IIIR (1987) ADHD (uncertain what ADHD looks like
without hyperactivity)
 DSM-IV (1994) ADHD- subtypes (predominantly
hyperactive-impulsive or predominantly inattentive or
combined type)
 DSM-V (2013) did not help much
DSM-5 (2013)
CRITERIA FOR ADHD: INATTENTION
 Makes careless mistakes or doesn’t pay close attention
 Difficulty in sustaining attention in tasks or play
 Doesn’t seem to listen when spoken to directly
 Do not follow through on instructions/fails to finish chores/tasks
 Difficulty organizing tasks and activities
 Avoids, dislikes or is reluctant to engage in tasks that require
sustained mental effort
 Often loses things necessary for tasks or activities
 Easily distracted by extraneous stimuli
 Often forgetful in daily activities
DSM- 5 (2013)
CRITERIA FOR ADHD: HYPERACTIVEIMPULSIVE
 Fidgets with hands or feet/squirms in seat
 Leaves seat in classroom
 Runs about/climbs excessively in situations where it is
inappropriate
 Difficulty playing/engaging in leisure activities quietly
 Often “on the go” or acts as if driven by a motor
 Talks excessively
 Blurts out answers before questions have been completed*
 Has difficulty awaiting turn*
 Interrupts or intrudes on others*
DSM- 5 CRITERIA FOR ADHD
 Some symptoms must occur before age 12 (used to be 7)
 Impairment must be present in two or more settings
 Must be clear evidence of clinically significant impairment in
social, academic or occupational functioning
 Must have at least 6 symptoms of either to be diagnosed
 Symptoms must have persisted for at least 6 months to a
degree that is maladaptive and inconsistent with
developmental level
CRITICISM OF DSM- 5
Subtypes are unstable over time
What is the nature of the relationship between
ADHD-PI and ADHD-PH?
Many kids with PI have no signs of HI, why do they
carry a diagnosis of AD(H)D?
Some symptoms are overly represented
(inattention), some under represented (impulsivity)
Age of onset is arbitrary
ADHD OVER TIME (TOPPELBERG, 2007)
DOES THE DSM-5 CAPTURE THIS?
3 to 5 years old: Motor restlessness, interrupting,
excessive tantrums, poor sense of time
6 to 12 years old: Easily distracted, poorly
organized, can’t wait turn, easily angry or frustrated,
poor sense of time
Ages 13 to 18: Inner restlessness, poor self-esteem,
disorganized school work, poor peer relations
Adulthood: Difficulty in initiating and finishing
projects, inattentive, loses things, disorganized at
home and school
IS SLUGGISH COGNITIVE TEMPO REAL?
Is “Sluggish Cognitve Tempo” a New
Disorder or an extension of ADHD?”
(New
York Times, April 22, 2014)
The Daydream Disorder (Slate, Sept. 29, 2014)
No Child Left Undiagnosed (Psychology Today, April
2014)
“SCT… fad in evolution… this is a public health experiment
on millions of kids.” (Frances, 2014)
SLUGGISH COGNITIVE TEMPO:
SYMPTOMS
Sluggish/sleepy items:
Apathetic
Drowsy/sleepy
Lost in thought
Lethargic
Sluggish slow moving
Daydreamy items:
Seems to be in a fog
Easily confused
Stares a lot
Spacey
CHARACTERISTICS OF SCT (BECKER, 2014)
 SCT not captured by DSM-5 ADHD
 Approximately 50% of people with ADHD show SCT
 Overall support for it being distinct from ADHD-Inattentive
type
 Distinct from Anxiety and Depression yet, strongly
comorbid with both particularly depression
 Little association with externalizing problems
 Consistently associated with social functioning
 Emotional dysregulation
ADHD PREVALENCE RATES
3 to 7.8% in U.S (Barkley, 2005)
5.2% world prevalence (Polanczyk, et al., 2007)
3:1 boys to girls (community sample)
9:1 boys to girls (clinical sample)
2:1 African-Americans to Caucasians
67% are diagnosed in childhood before 7 (Applegate,
1997)
 98% are diagnosed before 16 (Barkley, 2010)
 66% persist into adulthood (Barkley, 2005)
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ATTENTION DEFINED:
MEL LEVINE’S ONE MIND AT A TIME
 Attention: Gateway into learning
 Problems with attention: cascade of issues into other
systems
 Model:
1. Control over mental energy: sleep/arousal imbalance;
alertness
2. Control over intake (of info/stimuli): selection control;
relevance of info; impacts other modalities
3. Control over output: writing difficulties
EXECUTIVE FUNCTION
“THE CONTROL CENTER”
 “ ADHD is less an attentional disorder and more a
disorder of the executive functioning or of internally
guided and regulated behavior across time – and
toward future events. This leaves the person more
controlled by external events in the moment and more
governed by concern for immediate than for delayed
gratification.” (Barkley, 2007)
 Know what to do, but can’t do what they know (Barkely, 2007)
 ISIS- INITIATE, SUSTAIN, INHIBIT, SWITCH (Denckla, 1996)
IMPAIRMENT IN EXECUTIVE
FUNCTIONS
(GRODZINSKY, 2011)
 Distractibility
 Poor sustained attention and effort
 Difficulty planning to meet a goal
 Impulsivity
 Perseveration
 Rigidity
 Alterations in mood
 Lack of insight
 Inability to profit from experience
STROOP TEST
TRAIL MAKING TEST
RISK FACTORS
Heritability is high: .7 to .8
Diathesis-stress model revisited (gene-environment
interaction)
Prematurity/low birth weight***
Maternal smoking
Maternal alcohol consumption
Low SES: (may come with additional psychosocial
stressors)
PROTECTIVE FACTORS
(NIGG & NIKOLAS, 2008)
Stronger reading ability
Positive peer relations
Absence of aggressive behavior
Effective parenting
Good support network
COMORBIDITIES WITH ADHD
 Over 80% of kids with ADHD have an additional disorder
 Over 60% have two or more disorders
 Anxiety Disorders
 Depression: increases risk of suicide 2 to 4 times more than
solely ADHD
 ODD/CD
 Learning Disabilities
CHALLENGES
(HINSHAW, 2007)
Positive Illusory Bias: Kids with ADHD may not see
their interactions as problematic; limited selfawareness
Peer relations/peer rejection: one of the most
robust predictors of later school dropout
Academic underachievement
Decreased self-esteem
Compromised parent-child interactions
INTERVENTIONS
 High level anxiety/internalizing: poor response to stimulant
meds (Jensen et al., 2001)
 High level of hostile/defiant behavior: intensive family-based
interventions (Barkley et al., 1992)
 Medications: Stimulants (Ritalin, Adderall)
Non-Stimulants (Strattera)
 Parent training in contingency management
 Consistency between school and home
 Manageable goals, realistic expectations, extrinsic rewards
 Daily report cards
MEDICATION PROS & CONS
Lifesaving (reduces hyperactivity, impulsivity,
retaliatory aggression, distractibility)
May decrease motivation for parents/teachers
Medications don’t provide the tools for change,
they allow the child to concentrate and start
learning to use them
Sleep and appetite
Long-term risks?
ALL BRAINS ARE UNIQUE: ESSENTIAL
CHECKLIST FOR THOSE WORKING WITH KIDS WITH ADHD
(NOWELL, 2007)
 Fun to be around
Makes me laugh
 Enthusiastic
Takes risk
 Spontaneous
Brave
 Creative
Makes me feel like a kid
 High energy
 Has good intuition
 Curious
 Thinks quickly
Sees things differently