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ADHD/ODD/CD/Tic Disorders. Back to Basics April 11, 2011 Clare Gray MD FRCPC. Attention Deficit Hyperactivity Disorder. 3 - 7% school aged children male:female 3-6 : 1 Diagnostic Triad Inattentiveness Impulsivity Hyperactivity. Inattentive Symptoms . 6 or more, for 6 months or more

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adhd odd cd tic disorders

ADHD/ODD/CD/Tic Disorders

Back to Basics

April 11, 2011

Clare Gray MD FRCPC

attention deficit hyperactivity disorder
Attention Deficit Hyperactivity Disorder
  • 3 - 7% school aged children
  • male:female 3-6 : 1
  • Diagnostic Triad
    • Inattentiveness
    • Impulsivity
    • Hyperactivity
inattentive symptoms
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
inattentive symptoms1
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
hyperactivity symptoms
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
impulsivity symptoms
Impulsivity Symptoms
  • Often blurts out answers before questions have been completed
  • Often has difficulty awaiting turn
  • Often interrupts or intrudes on others
  • 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)
  • Types
    • Combined Type
    • Predominantly Inattentive Type
    • Predominantly Hyperactive/Impulsive Type
    • NOS
  • 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
  • Treatment
    • Medication
    • Psychosocial treatments
adhd treatment
ADHD Treatment
  • Medications
    • Stimulants
    • Antidepressants
    • Clonidine
    • Atypical antipsychotics
  • 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
contraindications to stimulants
Contraindications to Stimulants
  • Previous sensitivity to stimulants
  • Glaucoma
  • Symptomatic cardiovascular disease
  • Hyperthyroidism
  • Hypertension
  • MAO inhibitor
  • Use very carefully if history of substance abuse
  • Monitor Carefully if:
    • Motor tics
    • Marked anxiety
    • Tourette’s syndrome
    • Seizures
    • Very young (3-6 year olds)
stimulants side effects
Stimulants -- Side Effects
  • Delay of sleep onset
  • Reduced appetite
  • Weight loss
  • Tics
  • Stomach ache
  • Headache
  • Jitteriness
effectiveness of stimulants
Effectiveness of Stimulants
  • At least 70% response rate to first stimulant tried
  • 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
  • Psychosocial treatments
    • parent training
      • psychoeducation, behaviour management, support
    • school interventions
      • remediation, behaviour management,
    • individual therapy
      • anger management, supportive, CBT, psychoedn
oppositional defiant disorder
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
dsm iv criteria
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
odd diagnosis
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
odd epidemiology
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
etiology biological factors
Etiology – Biological Factors
  • Parent with DBD, mood disorder, substance abuse disorder
  • Maternal smoking during pregnancy
  • Abnormalities of prefrontal cortex
  • Altered 5HT, NA and DA
etiology psychological factors
Etiology – Psychological Factors
  • Poor relationship with parents (insecure attachment)
  • Neglectful/absent parent
  • Difficulty or inability to form social relationships
etiology social factors
Etiology – Social Factors
  • Poverty
  • Chaotic environment (lack of structure)
  • Lack of parental supervision
  • Lack of positive parental involvement
  • Inconsistent discipline
  • Abuse/neglect
odd management
ODD -- Management
  • Few controlled studies
  • Variety of options
    • behavior therapy
    • family therapy
    • parent management training
  • Treat comorbidities (ADHD)
conduct disorder
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
aggression to people and animals
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
destruction of property
destruction of property
  • Has deliberately engaged in fire setting with the intention of causing serious damage
  • Has deliberately destroyed others’ property
deceitfulness or theft
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
serious violation of rules
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
cd diagnosis
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
cd subtypes
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
cd subtypes1
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
associated features
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
Only 3 risk factors have been shown to be “causal”
    • harsh, inconsistent parenting
    • poor academic performance
    • exposure to parental discord
cd etiology
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
antisocial personality disorder
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
antisocial personality disorder1
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
antisocial personality disorder2
Antisocial Personality Disorder
  • At least 18 years of age
  • Evidence of CD, with onset before age 15 years
  • Not due to Schizophrenia or Mania
cd course
CD -- Course
  • < 50% of CD have severe and persistent antisocial problems as adults
cd protective factors
CD – Protective Factors
  • easy temperament
  • above average intelligence
  • competence at a skill
  • a good relationship with at least 2 caregiving adult
cd management
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
cd management1
CD -- Management
  • Pharmacological
    • to treat comorbid conditions
      • ADHD – stimulants
      • Depression - SSRIs
      • Anxiety - SSRIs
    • to treat CD alone
      • Impulsivity/Aggression - mood stabilizers, neuroleptics
  • 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
  • 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.
transient tic disorder
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
chronic tic disorder
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
tourette s disorder
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.
  • 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
  • Neuroleptics
    • Pimozide
    • Risperidone
  • Other options
    • Clonidine
  • Habit-reversal training (HRT)
    • Awareness training
      • accentuates sensitivity to tic sensations
    • Competing response training
      • taught a specific response pattern that would be incompatible with the tic
      • replaces the tic behaviour with a more appropriate competing response
Antares is the 15th brightest start in the sky
  • It is more than 1000 light years away
  • So just try to keep everything in perspective!!
Good Luck with the Exam!
  • Any questions –