Transcript Attention-Deficit/Hyperactivity Disorder (ADHD) Conduct Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD)
Conduct Disorder(CD)
Oppositional Defiant Disorder(ODD)
Dr. Oğuzhan Zahmacıoğlu
Yeditepe Üniversitesi Hastanesi
Çocuk ve Ergen Psikiyatrisi
History
• The symptoms of Attention-Deficit/Hyperactivity
Disorder were first described in a children's
book, "The Story of Fidgety Philip," written in
1845 by Dr. Heinrich Hoffman.
• In 1902, a series of lectures published by Sir
George F. Still described problematic impulsive
behaviors among a group of children.
History
• Twenty years later, an American physician Dr.
Bradley, observed that children treated with
stimulant medication showed fewer with
hyperactive and impulsive behaviors.
• During an outbreak of encephalitis in the 1940's,
physicians observed that affected children
displayed symptoms similar to those of
hyperactive children.
History
• As a result, the professional community
theorized that hyperactive children were brain
damaged.
• In response to this line of thinking, the first
stimulant medication, methylphenidate (Ritalin),
became commercially available in 1957.
History
• The concept of hyperactivity as a disorder
caused by something other than brain damage
was re-introduced by Stella Chess in 1960.
• She described the "Hyperactive Child
Syndrome" as an environmentally-based
problem caused by faulty parenting.
• Her theories led to a re-evaluation of the origins
of ADHD throughout the field.
History
• As a result of her work, the official medical name
of the disorder was changed to Minimal Brain
Dysfunction (MBD).
• Also, in 1965, the American Psychiatric
Association changed the name again to
"Hyperkinetic Reaction of Childhood," supporting
the theory that hyperactivity was not a biological
disorder, but rather, an environmental problem.
History
• In 1980, the term "Attention Deficit
Disorder", or ADD, "With and Without
Hyperactivity" was included in DSM-III
• The American definition used today was
introduced in 1994, in the DSM-IV.
Prevalence
• ADHD prevalence in community-based samples
have ranged from 2% to 26%.
• Persistence of ADHD into adulthood has been
shown to occur in 30 to 50% (or more) of
childhood cases
• In children, ADHD is 3-5 times more common in
boys than in girls.
• The predominantly inattentive type of ADHD is
found more commonly in girls than in boys.
The DSM-IV-TR criteria are as
follows(1):
• Must include at least 6 of the following symptoms of
inattention that must have persisted for at least 6
months to a degree that is maladaptive and inconsistent
with developmental level:
a)Often fails to give close attention to details or makes
careless mistakes in schoolwork, work, or other activities
b)Often has difficulty sustaining attention in tasks or play
activities
c)Often does not seem to listen to what is being said
The DSM-IV-TR criteria are as
follows(2):
d)Often does not follow through on instructions and fails
to finish schoolwork, chores, or duties in the workplace
(not due to oppositional behavior or failure to understand
instructions)
e)Often has difficulties organizing tasks and activities
f)Often avoids or strongly dislikes tasks (such as
schoolwork or homework) that require sustained mental
effort
g)Often loses things necessary for tasks or activities
(school assignments, pencils, books, tools, or toys)
h)Often is easily distracted by extraneous stimuli
I)Often forgetful in daily activities
The DSM-IV-TR criteria are as
follows(3):
• Must include at least 6 of the following
symptoms of hyperactivity-impulsivity that
must have persisted for at least 6 months to a
degree that is maladaptive and inconsistent with
developmental level:
a)Hyperactivity evidenced by fidgeting with
hands or feet, squirming in seat
b)Hyperactivity evidenced by leaving seat in
classroom or in other situations in which
remaining seated is expected
The DSM-IV-TR criteria are as
follows(4):
c)Hyperactivity evidenced by running about or climbing
excessively in situations where this behavior is
inappropriate (in adolescents or adults, this may be
limited to subjective feelings of restlessness)
d)Hyperactivity evidenced by difficulty playing or
engaging in leisure activities quietly
e)Impulsivity evidenced by blurting out answers to
questions before the questions have been completed
f)Impulsivity evidenced by showing difficulty waiting in
lines or awaiting turn in games or group situations
The DSM-IV-TR criteria are as
follows(5):
• Impulsivity
g)often blurts out answers before
questions have been completed
h) often has difficulty awaiting turn
ı) often interrupts or intrudes on others
(e.g., butts into conversations or games)
The DSM-IV-TR criteria are as
follows(6):
• B. Some hyperactive-impulsive or inattentive symptoms
that caused impairment were present before age 7
years.
• C. Some impairment from the symptoms is present in
two or more settings (e.g., at school [or work] and at
home).
• D. There must be clear evidence of clinically significant
impairment in social, academic, or occupational
functioning.
• E. The symptoms do not occur exclusively during the
course of a PDD, Schizophrenia, or other Psychotic
Disorder and are not better accounted for by another
mental disorder (e.g., Mood Disorder, Anxiety Disorder,
Dissosiative Disorders, or a Personality Disorder).
Pathophysiology
• Any pathophysiologic theory about ADHD
must address the large pharmacotherapy
literature about the disorder.
• The aetiology and pathogenesis of ADHD
is only partly understood.
• it is a complex, multi-factorial disorder
caused by the interaction of many different
types of risk factors (i.e., genetic,
biological, environmental, psychosocial)
Pathophysiology
• The latest findings on the genetics of
ADHD suggesting that dopaminergic,
serotonergic, and noradrenergic
neurotransmission pathways account for
the aetiology of this complex disorder.
• The underlying brain regions
predominantly thought to be involved are
frontal and prefrontal.
Treatment
• Methylphenidate (Ritalin)
• Methylphenidate HCl (Concerta)
has methylphenidate as its active ingredient.
differentiates itself from other methylphenidate pills by a special
time-release technology.
• Atomoxetine (Strattera) a SNRI, a non-stimulant drug
• Tricyclics like Desipramine and Imipramine
• Bupropion hydrochloride both dopaminergic and noradrenergic effects
Psychostimulants
• - improve 70-90% of ADHD children aged
5+
• - thought to act by increasing dopamine
transmission
• - Ritalin (methylphenidate): most common
treatment
• - blocks recycling of dopamine
• - Dexedrine, Adderall, Cylert
Behavior therapy needed for problems
with:
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parent-child relations
disruptive behavior
poor academic performance
anxiety
social skills
Most effective treatment
is
Individually tailored doses of medication
+
behavior therapy
Possible drug mechanisms
• Stimulants block the reuptake of dopamine
and norepinephrine into the presynaptic
neuron and increase the release of these
monoamines into the extraneuronal space
• Alteration of monoaminergic transmission
in critical brain regions may be the basis
for stimulant action in ADHD
Prognosis
• At least an estimated 15-20% of children
with ADHD maintain the full diagnosis into
adulthood. As many as 65% of these
children will have ADHD or some residual
symptoms of ADHD as adults
Conduct Disorder
• The primary diagnostic features of conduct
disorder include aggression, theft,
vandalism, violations of rules and/or lying.
• Conduct disorder has a multifactorial
etiology that includes biologic,
psychosocial and familial factors.
• has two subtypes: childhood onset and
adolescent onset.
Conduct Disorder
• Childhood conduct disorder, left untreated, has a
poorer prognosis.
• In about 40 percent of cases, childhood-onset
conduct disorder develops into adult antisocial
personality disorder.
• Adolescents exhibiting conduct disorder
behavior as a part of gang culture or to meet
basic survival needs (e.g., stealing food) are
often less psychologically disturbed than those
with early childhood histories of behavior
disorders.
Conduct Disorder
• New-onset conduct disorder behavior,
such as skipping school, shoplifting or
running away, in the context of a family
stressor, often remits if appropriate
structure and support are provided.
Conduct Disorder
• Children who have conduct disorder may inherit
decreased baseline autonomic nervous system
activity, requiring greater stimulation to achieve
optimal arousal.
• Parental substance abuse, psychiatric illness,
marital conflict, and child abuse and neglect all
increase the risk of conduct disorder
• Exposure to the antisocial behavior of a
caregiver is a particularly important risk factor.
Conduct Disorder
• Another common feature appears to be
inconsistent parental availability and
discipline.
• Children with conduct disorder generally
do not experience a consistent relationship
between their behavior and its
consequences.
Conduct Disorder
• a repetitive and persistent pattern of
behavior in which the basic rights of
others, or major rules and values of
society are violated, as shown by the
presence of three (or more) of the
following behavior patterns in the past 12
months, with at least one behavior pattern
present in the past six months:
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
(for example, a bat, brick, broken bottle, knife, gun).
• Has been physically cruel to people.
• Has been physically cruel to animals.
• Has stolen while confronting a victim (for example, mugging, purse
snatching, extortion, armed robbery.
• Has forced someone into sexual activity
Destruction of property:
• Has deliberately engaged in fire setting
with the intention of causing serious
damage.
• Has deliberately destroyed others'
property (other than by fire setting).
Deceitfulness or theft:
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Has broken into someone else's house,
building, or car.
Often lies to obtain goods or favors or to
avoid obligations (in other words, "cons"
others)
Has stolen items of nontrivial value
without confronting a victim (for example,
shoplifting, but without breaking and
entering; forgery).
Serious violations of rules:
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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 age 13 years
Conduct Disorder
• the disturbance in behavior must be
causing significant problems in that
person's life, including at school, with
friends and family, and on the job.
• some research is now beginning to show
that conduct disorder may be a
component of childhood bipolar
disorder
Keep in mind that this behavior
disorder consists of a pattern of
severe, repetitive acting-out
behavior and not of an isolated
incident here and there
!
Intervention
• Physicians should emphasize the
seriousness of the patient's behavior and
the possibility of a poor long-term
prognosis if there is no significant parental
intervention.
Practical Interventions for Management of Patients
with Conduct Disorder
• Assess severity and refer for treatment
with a subspecialist as needed.
• Treat comorbid substance abuse first.
• Describe the likely long-term prognosis
without intervention to caregiver.
• Structure children's activities and
implement consistent behavior guidelines.
• Emphasize parental monitoring of
children's activities
Practical Interventions for Management of
Patients with Conduct Disorder
• Encourage children's involvement in structured
and supervised peer activities
• Discuss and demonstrate clear and specific
parental communication techniques.
• Help caregivers establish appropriate rewards
for desirable behavior.
• Help establish realistic, clearly communicated
consequences for noncompliance.
Practical Interventions for Management of
Patients with Conduct Disorder
• Help establish daily routine of childdirected play activity with parent(s).
• Consider pharmacotherapy for children
who are highly aggressive or impulsive, or
both, or those with mood disorder.
Pharmacotherapy for Conduct
Disorder
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Stimulants
Antidepressants
Anticonvulsants
Antipsychotics
Oppositional Defiant Disorder
• According to the DSM-IV, if a child's
problem behaviors do not meet the criteria
for Conduct Disorder, but involve a pattern
of defiant, angry, antagonistic, hostile,
irritable, or vindictive behavior,
Oppositional Defiant Disorder may be
diagnosed. These children may blame
others for their problems.
• Oppositional Defiant Disorder is a pattern of negativistic,
hostile, and defiant behavior lasting at least six months,
during which four (or more) of the following are present:
• Often loses temper.
• Often argues with adults.
• Often actively defies or refuses to comply with adults' requests or
rules.
• Often deliberately annoys people.
• Often blames others for his or her mistakes or misbehavior.
• Is often touchy or easily annoyed by others.
• Is often angry and resentful.
• Is often spiteful or vindictive.