1. ADHD/ODD/CD Back to Basics April 24, 2008 Clare Gray MD FRCPC

2. Attention Deficit Hyperactivity Disorder 3 - 7% school aged children male:female 3-6 : 1 Diagnostic Triad –Inattentiveness –Impulsivity –Hyperactivity

3. 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

4. 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

5. 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

6. Impulsivity Symptoms Often blurts out answers before questions have been completed Often has difficulty awaiting turn Often interrupts or intrudes on others

7. ADHD 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)

8. ADHD Types –Combined Type –Predominantly Inattentive Type –Predominantly Hyperactive/Impulsive Type –NOS

9. ADHD 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

10. ADHD Treatment –Medication –Psychosocial treatments

11. ADHD Treatment Medications –Stimulants –Antidepressants –Clonidine –Atypical antipsychotics

12. Stimulants Methylphenidate –Ritalin (regular, slow release) –OROS Methylphenidate (Concerta) Dextroamphetamine –Dexedrine (regular, slow release) Adderrall XR –Mixed amphetamine salts

13. Contraindications to Stimulants Previous sensitivity to stimulants Glaucoma Symptomatic cardiovascular disease Hyperthyroidism Hypertension MAO inhibitor Use very carefully if history of substance abuse

14. Stimulants Monitor Carefully if: –Motor tics –Marked anxiety –Tourette’s syndrome –Seizures –Very young (3-6 year olds)

15. Stimulants -- Side Effects Delay of sleep onset Reduced appetite Weight loss Tics Stomach ache Headache Jitteriness

16. Effectiveness of Stimulants At least 70% response rate to first stimulant tried –Fewer than half show total normalization

17. Others Buproprion (Wellbutrin) Atomoxetine (Strattera)

18. ADHD Psychosocial treatments –parent training psychoeducation, behaviour management, support –school interventions remediation, behaviour management, –individual therapy anger management, supportive, CBT, psychoedn

19. 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

20. 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

21. 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

22. ODD -- Epidemiology prevalence rates (lots of different data!) 2 - 16 % more common in males 2:1 or 3:1 males:females peak age of onset 6.5 years cases rarely onset after age 10

23. ODD -- Etiology Etiology is “multifactorial” Combination of genetic and environmental factors Family history of disruptive behavior disorders, mood disorders, ASPD or substance abuse –Increased rates of ODD with maternal depression

24. ODD -- Etiology Parenting style (permissive, inconsistent discipline, unavailable) Harsh inconsistent neglectful child rearing practices Multiple successive caregivers Family and marital discord

25. ODD -- Management Few controlled studies Variety of options –behavior therapy –family therapy –parent management training Treat comorbidities (i.e.. ADHD)

26. 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

27. 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

28. destruction of property Has deliberately engaged in fire setting with the intention of causing serious damage Has deliberately destroyed others’ property

29. 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

30. 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

31. 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

32. 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

33. 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

34. CD -- Subtypes Adolescent-Onset (cont’d) –less frequently see ODD, hyperactivity and school failure –more likely to be related to peer activities –limited to adolescence -- rarely continues into adulthood –seldom see onset after 16 years of age

35. 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

36. Factors for Poor Prognosis Parental rejection and neglect Difficult infant temperament Inconsistent child-rearing practices with harsh discipline Physical or sexual abuse Lack of supervision Early institutional living Frequent changes of caregivers Large family size

37. Factors for Poor Prognosis (cont’d) Childhood-onset CD Comorbid ADHD High level of aggression Low intelligence Early court involvement Peer rejection Substance abuse

38. CD -- Epidemiology CD is one of the most frequently diagnosed conditions in mental health facilities prevalence – 2 to 10 % –boys 6 to 16% –girls 2 to 9% peak age of onset is 9 y.o. seldom see onset after 16 y.o.

39. CD -- Etiology Multifactorial 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

40. 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

41. 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

42. Antisocial Personality Disorder At least 18 years of age Evidence of CD, with onset before age 15 years Not due to Schizophrenia or Mania

43. CD -- Course < 50% of CD have severe and persistent antisocial problems as adults

44. CD – Protective Factors easy temperament above average intelligence competence at a skill a good relationship with at least 2 caregiving adult

45. 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

46. CD -- Management Pharmacological –to treat comorbid conditions ADHD - stimulants, clonidine Depression - SSRIs Anxiety - SSRIs, Buspirone –to treat CD alone Impulsivity/Aggression - mood stabilizers, neuroleptics Hyperactivity - stimulants, clonidine

47. Enuresis and Encopresis Clare Gray MD FRCPC April 24, 2008

48. Enuresis and Encopresis Enuresis –repeated voiding of urine into bed or clothes –frequency of twice a week for 3 consecutive months or impairment in functioning –at least 5 years old –not due to substance or medical condition

49. Enuresis Nocturnal only Diurnal only Nocturnal/Diurnal Prevalence –7-10% boys, 3% girls –4:1 male:female ratio –approx. 3% of boys and 2% of girls have problems at age 10

50. Enuresis Parents may see a child’s failure to toilet train as a reflection of their inadequacy as parents symptoms become a closely guarded secret anger, frustration and anxiety can occur parents may become harsh and punitive

51. Enuresis Physiological causes –Urologic conditions infection, obstruction –Anatomic abnormalities congenital anomalies, weak bladder –Neurologic disorders seizures, MR, spinal cord disease –Metabolic disorders diabetes

52. Enuresis Functional enuresis –stress, trauma, psychological crisis –50% have comorbid emotional and behavioural symptoms –revenge, regression, lack of training Primary enuresis vs Secondary enuresis

53. Enuresis Treatment –wait for spontaneous resolution 15% per year –Behavioural treatment bladder training exercises, alarms restricting nighttime fluid intake, awakenings for toilet use, star charting –Medications Imipramine (“gold standard”), DDAVP

54. Encopresis Repeated passage of feces into inappropriate places one event a month for 3 months chronological age of at least 4 years not due to substance or medical condition except through a mechanism involving constipation

55. Encopresis Embarrassing and stigmatizing condition can be either primary or secondary (50 to 60%) by age 4, approx 95% of children have attained bowel continence prevalence –0.3 to 8% with male:female 4:1

56. Encopresis Punitive and coercive toilet training can create stress and anxiety -- toilet phobia other life stressors (birth of sibling) early toilet training

57. Encopresis Treatment –Behavioural consistent motivation and interest praise make the bathroom a pleasant and nonthreatening place star charts, rewarding appropriate behaviours –Medications treat constipation -- diet, laxatives etc