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MSFP
ADHD, ODD & CD
| Term | Definition |
|---|---|
| ATTENTION - DEFICIT HYPERACTIVITY DISORDER (ADHD) • Early 1900s: | “hyperactive syndrome” - impulsive, disinhibited, and hyperactive children even those with neurological damage due to encephalitis |
| ATTENTION - DEFICIT HYPERACTIVITY DISORDER (ADHD) ● In 1960s: | “minimal brain damage” - a heterogeneous group of children with poor coordination, learning disabilities, and emotional lability, but without specific neurological disorders |
| ATTENTION - DEFICIT HYPERACTIVITY DISORDER (ADHD) 1 | ● Symptoms including theories of abnormal arousal and poor ability to modulate emotions - supported by the observation that stimulant medications increased sustained attention and improved focus |
| ATTENTION - DEFICIT HYPERACTIVITY DISORDER (ADHD) 2 | ● Persistent pattern of inattention and/or hyperactivity impulsivity that interferes with functioning or development |
| Inattention | manifests behaviorally as wandering off task, lacking persistence, having difficulty sustaining focus, and being disorganized and is not due to defiance or lack of comprehension |
| Hyperactivity | refers to excessive motor activity (such as a child running about) when it is not appropriate, or excessive fidgeting, tapping, or talkativeness |
| Hyperactivity in adults | may manifest as extreme restlessness or wearing others out with their activity. |
| Impulsivity | refers to hasty actions that occur in the moment without forethought and that have high potential for harm to the individual (e.g., darting into the street without looking) |
| Impulsive behaviors | may manifest as social intrusiveness (e.g., interrupting others excessively) and/or as making important decisions without consideration of long-term consequences (e.g., taking a job without adequate information) |
| 15 % | Inattention ● Associated with anxiety and depression |
| 5 % | Hyperactivity-impulsivity ● Associated with oppositional defiant disorder and conduct disorder |
| 80 % | Combined |
| ADHD PREVALENCE | ● Most common chronic behavioral disorder in children ● Males > females ● 2:1 in children and 1.6:1 in adults ● The rate of ADHD in parents and siblings of children with ADHD is 2-8 times greater than in the general population |
| ADHD ETIOLOGY 1 | ● No single underlying cause ● Motor dyspraxia, tics, learning problems, speech and language disorders, sleep disorders, oppositional behavior, enuresis, and encopresis |
| ADHD ETIOLOGY 2 | ● Overactive and socially disruptive behavior is common in children who have evidence of injury from infections, head trauma, toxic exposures, and extreme prematurity head trauma, toxic exposures, and extreme prematurity |
| ADHD NEUROBIOLOGIC BASIS AND GENETICS 1 | ● Families of ADHD/CD children are notable for the high incidence of sociopathy and alcoholism ● Highly heritable |
| ADHD NEUROBIOLOGIC BASIS AND GENETICS 2 | ● Several linkage studies implicate a 7-repeat polymorphism of the dopamine receptor D4 (DRD4) gene, mapped to chromosome 11p 15.5, and also a polymorphism of a dopamine transporter (DAT1) |
| The prefrontal cortex of the brain has been implicated because of its high utilization of ________ and its reciprocal connections with other brain regions | dopamine |
| Animal studies have shown that other brain regions such as locus coeruleus, which consists predominantly of _________________, also play a major role in attention | noradrenergic neurons |
| Neuroanatomical areas involved in ADHD: | ● superior and temporal cortices ● external parietal and corpus striatal regions ● hippocampus ● prefrontal cortex |
| superior and temporal cortices | focusing attention |
| external parietal and corpus striatal regions | motor executive functions |
| hippocampus | encoding of memory traces |
| prefrontal cortex | shifting from one stimulus to another |
| right frontal lobe | is reportedly smaller than normal in ADHD structural imaging, and the striatum has abnormal morphology |
| cerebellar, temporal gray matter, and total cerebral volume | are smaller |
| Corpus callosum size | is reduced as well as the inferior cerebellar vermis, posterior lobe |
| Regional cerebral blood flow is diminished in ________________________ in ADHD | striatum and frontal lobes |
| Power spectrum analysis indicates prefrontal under activation and cerebral glucose metabolism is diminished generally, but most notably, in the ______________ | prefrontal cortex |
| ADHD - RISK FACTORS ● Temperamental | ○ Associated with reduced behavioral inhibition, effortful control, or constraint; negative emotionality; and/or elevated novelty seeking |
| ADHD - RISK FACTORS ● Environmental | ○ Very low birth weight, smoking during pregnancy, history of child abuse, maltreatment, neglect, multiple foster placements, neurotoxin exposure (lead), infections (encephalitis), or alcohol exposure in utero, exposure to environmental toxicants |
| ADHD - RISK FACTORS ● Course modifiers | ○ Family interaction patterns in early childhood may influence its course or contribute to secondary development of conduct problems |
| Etiologic Clue: Environmental | Description of Findings: Increased incidence of behavioral disorders, sociopathy, and alcoholism in families of children with ADHD |
| Etiologic Clue: Endocrine | Description of Findings: Increased frequency of ADHD in patients with resistance to thyroid hormone in some studies |
| Etiologic Clue: Genetic | Description: ○ Increased concordance for hyperactivity/inattentiveness in monozygotic twins (59% to 81%) compared w/ dizygotic twins (approx 1/3) ○ Increased incidence of ADHD in 1st-degree (up to 25%) and 2nd-degree relatives of children w/ ADHD |
| Etiologic Clue: Neuroanatomy Cerebrum 1 | Description: ○ Some limited magnetic resonance imaging brain morphology and neuropsychologic studies suggest that children with ADHD have a smaller or functionally abnormal right frontal lobe; |
| Etiologic Clue: Neuroanatomy Cerebrum 2 | Description: ○ other studies show variable asymmetries and volumetric differences in the basal ganglia, corpus callosum, ventricular systems, and subcortical white matter |
| Etiologic Clue: Electroencephalographic findings | Description: Increased anterior absolute theta and decreased posterior relative beta activity in quantified electroencephalographic analysis suggests reduced cortical arousal in adolescents with ADHD |
| Etiologic Clue: Brainstem 1 | Description: Prolonged latencies of waves Ill and V, and longer brainstem transmission of waves I-Ill and I-V in brainstem auditory-evoked potentials of children with ADHD suggest brainstem dysfunction in these children |
| Etiologic Clue: Brainstem 2 | Description: Activation of reticular midbrain formation and thalamic intralaminar nuclei increases on attention-demanding tasks in a positron emission tomographic study, executive functioning associated w/ greater subcortical activation in ADHD subjects |
| Etiologic Clue: Neurochemistry Dopaminergic and noradrenergic systems 1 | Description: Pharmacologic agents that are effective in ADHD (e.g. stimulants and tricyclic antidepressants) increase central nervous system dopamine and norepinephrine transmission |
| Etiologic Clue: Neurochemistry Dopaminergic and noradrenergic systems 2 | Description: Dopamine deficiency is lack of impulse control in ADHD; studies that measure catecholamines and metabolites in individuals with ADHD are inconclusive; regional dopamine inhibitory autoreceptors may play a role in CNS catecholamine metabolism |
| Etiologic Clue: Neurochemistry Dopaminergic and noradrenergic systems 3 | Description: Functional neuroimaging studies support the hypothesis that attention is regulated at multiple levels, especially frontal, parietal, or temporal cortex as well as subcortical structures within the basal ganglia and thalamus |
| ADHD CLINICAL FEATURES | ● Signs begin before age 7 years and should persist for at least 6 months in two or more settings |
| Second year of life was found to be the earliest in which ADHD symptoms could be detected and age ____________ to be the peak time of onset | 3 to 5 years |
| ADHD Primary manifestations: | cognitive disorganization, distractibility, inattention, impulsivity, and hyperactivity |
| ADHD Secondary manifestations: | disruptive behaviors, poor social skills, emotional immaturity, fidgeting, poor academic performance, and excessive talking |
| _____________________________ in infancy and the preschool period are commonly reported precursors | Feeding difficulty and sleep disturbances |
| ___________________________ explore their environment with unusual persistence, which accounts for the increased frequency of accidental poisonings and traumatic brain injury in ADHD | Young children with hyperactivity |
| ___________________________ initially show no signs of distress, but negative reactions from adults and peers gradually engender feelings of inadequacy, and this can lead to withdrawal or aggression | Young children with ADHD |
| _____________________ are seen as quarrelsome, irritable, defiant, untruthful, and destructive | Hyperactive children |
| Non-hyperactive children with attention deficit | are misperceived as undermotivated or lazy, and the diagnosis is often missed |
| ADHD Diagnostic Criteria 1. Inattention 1 Six (or more) of the following symptoms have persisted for at least 6 months: | a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities b. Often has difficulty sustaining attention in tasks or play activities |
| ADHD Diagnostic Criteria 1. Inattention 2 Six (or more) of the following symptoms have persisted for at least 6 months: | c. Often does not seem to listen when spoken to directly d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace e. Often has difficulty organizing tasks and activities |
| ADHD Diagnostic Criteria 2. Inattention 3 Six (or more) of the following symptoms have persisted for at least 6 months: | f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort g. Often loses things necessary for tasks or activities h. Often easily distracted by extraneous stimuli i. Is often forgetful in daily activities |
| Often easily distracted by extraneous stimuli | for older adolescents and adults, may include unrelated thoughts |
| ADHD Diagnostic Criteria 2. Hyperactivity and impulsivity 1 Six (or more) of the following symptoms have persisted for at least 6 months: | a. Often fidgets with or taps hands or feet or squirms in seat b. Often leaves seat in situations when remaining seated is expected c. Often runs about or climbs in situations where it is inappropriate |
| ADHD Diagnostic Criteria 2. Hyperactivity and impulsivity 2 Six (or more) of the following symptoms have persisted for at least 6 months: | d. Often unable to play or engage in leisure activities quietly. e. Is often "on the go," acting as if "driven by a motor' f. Often talks excessively |
| ADHD Diagnostic Criteria 2. Hyperactivity and impulsivity 3 Six (or more) of the following symptoms have persisted for at least 6 months: | g. Often blurts out an answer before a question has been completed h. Often has difficulty waiting his or her turn i. Often interrupts or intrudes on others |
| Often runs about or climbs in situations where it is inappropriate | In adolescents or adults, may be limited to feeling restless |
| ADHD Diagnostic Criteria A. Inattention and Hyperactivity-impulsivity For older adolescents and adults (age 17 and older): | at least five symptoms are required |
| ADHD Diagnostic Criteria B. Several inattentive or hyperactive-impulsive symptoms were present prior to age _____ | 12 years |
| ADHD Diagnostic Criteria C. Several inattentive or hyperactive-impulsive symptoms are present in ______________ settings | two or more |
| ADHD Diagnostic Criteria D: | D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning |
| ADHD Diagnostic Criteria E: | E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder |
| ADHD Diagnostic Criteria ● Specify whether: 314.01 (F90.2) Combined presentation | If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months. |
| ADHD Diagnostic Criteria ● Specify whether: 314.00 (F90.0) Predominantly inattentive presentation: | If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months. |
| ADHD Diagnostic Criteria ● Specify whether: 314.01 (F90.1) Predominantly hyperactive/impulsive presentation: | If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. |
| ADHD Diagnostic Criteria ● Specify if: in partial remission | When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning. |
| ADHD Diagnostic Criteria ● Specify current severity: MILD | Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. |
| ADHD Diagnostic Criteria ● Specify current severity: MODERATE | Symptoms or functional impairment between "mild" and "severe" are present. |
| ADHD Diagnostic Criteria ● Specify current severity: SEVERE | Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning. |
| ADHD ASSOCIATED FEATURES SUPPORTING DIAGNOSIS 1 | ● Mild delays in language, motor, or social development often co occur ● Low frustration tolerance, irritability, or mood lability ● Academic or work performance is often impaired |
| ADHD ASSOCIATED FEATURES SUPPORTING DIAGNOSIS 2 | ● Cognitive problems on tests of attention, executive function, or memory ● By early adulthood, ADHD is associated with an increased risk of suicide attempt, primarily when comorbid with mood, conduct, or substance use disorders |
| ADHD DEVELOPMENT AND COURSE 1 | ● Most often identified during elementary school years ● The disorder is relatively stable through early adolescence, but some individuals have a worsened course with development of antisocial behaviors |
| ADHD DEVELOPMENT AND COURSE 2 | ● In most individuals, symptoms of motoric hyperactivity become less obvious in adolescence and adulthood, but difficulties with inattention, poor planning, and impulsivity persist |
| ADHD DEVELOPMENT AND COURSE 3 | ● Persistence is predicted by a family history ● Most patients, however, undergo partial remission and are vulnerable to antisocial behavior, substance use disorders, and mood disorders |
| Remission | ● Occurs usually between the ages of 12 and 20 ● Can be accompanied by a productive adolescence and adult life, satisfying interpersonal relationships, and few significant sequelae |
| ADHD FUNCTIONAL CONSEQUENCES 1 | ● Reduced school performance and academic attainment, social rejection ● In adults, poorer occupational performance, attainment, attendance, and higher probability of unemployment as well as elevated interpersonal conflict |
| ADHD FUNCTIONAL CONSEQUENCES 2 | ● More likely to develop conduct disorder in adolescence ● Develop antisocial personality disorder in adulthood, consequently increasing the likelihood for substance use disorders and incarceration |
| ADHD FUNCTIONAL CONSEQUENCES 3 | ● The risk of subsequent substance use disorders is elevated, especially when conduct disorder or antisocial personality disorder develops ● Traffic accidents and violations are more frequent in drivers with ADHD |
| ADHD FUNCTIONAL CONSEQUENCES 4 | ● Inadequate or variable self-application to tasks that require sustained effort is often interpreted by others as laziness, irresponsibility, or failure to cooperate ● Family relationships may be characterized by discord and negative interactions |
| ADHD FUNCTIONAL CONSEQUENCES 5 | ● Peer relationships are often disrupted by peer rejection, neglect, or teasing of the individual with ADHD ● In its severe form, the disorder is markedly impairing, affecting social, familial, and scholastic/occupational adjustment |
| Academic deficits, school-related problems, and peer neglect | Most associated with elevated symptoms of inattention |
| Peer rejection and, to a lesser extent, accidental injury | Most salient with marked symptoms of hyperactivity or impulsivity |
| ADHD DIFFERENTIAL DIAGNOSES 1 | ● Oppositional defiant disorder (ODD) ● Intermittent explosive disorder (IED) ● Other neurodevelopmental disorders ● Specific learning disorder ● Intellectual disability ● Autism spectrum disorder ● Anxiety disorder ● Mood disorder |
| ADHD DIFFERENTIAL DIAGNOSES 2 | ● Disruptive mood dysregulation disorder ● Reactive attachment disorder ● Substance use disorders ● Personality disorders ● Psychotic disorders ● Medication induced symptoms of ADHD ● Disordered sleep ● Sydenham's chorea |
| ADHD DIFFERENTIAL DIAGNOSES ● Intermittent explosive disorder (IED) | ○ Serious aggression toward others |
| ADHD DIFFERENTIAL DIAGNOSES ● Other neurodevelopmental disorders | ○ Tics and stereotypies |
| ADHD DIFFERENTIAL DIAGNOSES ● Autism spectrum disorder | ○ ASD has fixations, tantrums, and irritability |
| ADHD DIFFERENTIAL DIAGNOSES ● Disruptive mood dysregulation disorder | ○ Pervasive irritability and intolerance frustration ○ Disorganized behavior isn’t a characteristic |
| ADHD DIFFERENTIAL DIAGNOSES ● Reactive attachment disorder | ○ Social inhibition |
| ADHD DIFFERENTIAL DIAGNOSES ● Substance use disorders | ○ Usually comorbid with ADHD |
| ADHD DIFFERENTIAL DIAGNOSES ● Personality disorders | ○ Cluster B — adolescents and adults |
| ADHD DIFFERENTIAL DIAGNOSES ● Sydenham's chorea | ○ Secondary to streptococcus infection |
| ADHD COMORBIDITY 1 | ● In the general population, oppositional defiant disorder co-occurs with ADHD in approximately half of children with the combined presentation and about a quarter with the predominantly inattentive presentation |
| ADHD COMORBIDITY 2 | ● Conduct disorder co-occurs in about a quarter of children or adolescents w/ combined presentation, depending on age and setting ● Most children and adolescents w/ disruptive mood dysregulation disorder have symptoms that also meet criteria for ADHD; |
| ADHD COMORBIDITY 3 | ● a lesser percentage of children with ADHD have symptoms that meet criteria for disruptive mood dysregulation disorder ● Specific learning disorder commonly co-occurs with ADHD |
| ADHD COMORBIDITY 4 | ● Although substance use disorders are relatively more frequent among adults with ADHD in the general population, the disorders are present in only a minority of adults with ADHD ● In adults, antisocial and other personality disorders may co-occur |
| ADHD COMORBIDITY ● Occur in a minority of individuals with ADHD but more often than in the general population: | ● Anxiety disorders and major depressive disorder ● Intermittent explosive disorder |
| ADHD DIAGNOSIS AND LAB EXAMINATION 1 | ● Comprehensive psychiatric and medical history ● Prenatal, perinatal, and toddler information should be included ● Complications of mother’s pregnancy |
| ADHD DIAGNOSIS AND LAB EXAMINATION 2 | ● Medical problems that may produce symptoms overlapping with ADHD include petit mal epilepsy, hearing and visual impairments, thyroid abnormalities, and hypoglycemia ● A thorough cardiac history should be taken |
| ADHD DIAGNOSIS AND LAB EXAMINATION 3 | ● Physical examination, blood pressure, pulse, weight, and height should be taken before treatment and monitored ● No specific laboratory measures are pathognomonic of ADHD |
| ADHD PHARMACOLOGIC TREATMENT ● STIMULANT MEDICATIONS | ● Improve behavioral control, and permit a more adaptive disposition of attention in relation to the demands of the moment ● Methylphenidate ● Pemoline ● Modafinil |
| Methylphenidate | ○ Inhibits receptor uptake of dopamine by blocking the dopamine transporter (DAT1) ○ Optimal doses range between 10-50 mg per day ○ The long-acting methylphenidate preparation (Ritalin sustained release) is effective for approximately 6 hours |
| Modafinil | ○ CNS stimulant made for narcolepsy (daytime sleepiness) ○ Needs FDA approval as it may cause skin rash |
| ADHD PHARMACOLOGIC TREATMENT ● ALTERNATIVES | ● Despiramine or risperidone ● Dexedrine ● Clonidine and guanfacine ● Tricyclic antidepressants or Selective serotonin reuptake inhibitors ● Norepinephrine ● reuptake inhibitor ● Barbiturates ● Methylxanthines |
| Clonidine and guanfacine, α2-adrenergic receptor agonists and antihypertensives | are alternative medications that ameliorate ADHD symptoms—frequently associated with aggression |
| Clonidine AE: | cardiovascular complications, especially when combined with methylphenidate |
| Guanfacine | appears to be less sedating and less apt to cause hypotension than clonidine, and it has a longer half-life |
| atomoxetine | ○ A more recently, a norepinephrine reuptake inhibitor, with a usual half-life of 5 hours, was found to ameliorate ADHD behavior ○ may be beneficial in the treatment of nonresponders with the use of stimulants |
| methylphenidate | Side effects such as anorexia and weight loss occur at frequencies. Acute liver failure is a rare complication |
| Tricyclic antidepressants or selective serotonin reuptake inhibitors | may assist in hyperactivity management, particularly in the presence of depressed affect |
| Barbiturates | ○ used for antiepileptic therapy, have a sedative effect and aggravate hyperactivity ○ When this occurs, nonbarbiturate antiepileptic drugs should gradually be substituted |
| Methylxanthines | such as caffeine and theophylline do not appear to have adverse behavioral effects in children. They may even have a mild positive effect on some externalizing behaviors |
| ADHD NON-PHARMACOLOGIC TREATMENT ● Avoid factors that might precipitate hyperactive behavior: | fluorescent lighting; heavy metals; certain natural foods, notably sugar; and certain food additives, especially dyes |
| ADHD NON-PHARMACOLOGIC TREATMENT ● Psychosocial interventions for children with ADHD include: | psychoeducation, academic organization skills remediation, parent training, behavior modification in the classroom and at home, cognitive behavioral therapy (CBT), and social skills training |
| ADHD NON-PHARMACOLOGIC TREATMENT 1 | ● Another goal of therapy is to help parents of children w/ ADHD recognize and promote the notion that, although the child may not “voluntarily” exhibit symptoms of ADHD, he or she is still capable of being responsible for meeting reasonable expectations |
| ADHD NON-PHARMACOLOGIC TREATMENT 2 | ● Short courses of supportive psychotherapy can help to reduce intrafamily tensions that aggravate, or sometimes even precipitate, restless and impulsive behavior |
| ADHD NON-PHARMACOLOGIC TREATMENT ● Group therapy aimed: | At both refining social skills and increasing self-esteem and a sense of success may be very useful for children with ADHD who have great difficulty functioning in group settings, especially in school |
| ADHD NON-PHARMACOLOGIC TREATMENT ● A multimodality regime including intensive psychotherapy: | reduced the incidence of antisocial behavior in an ADHD cohort |
| ADHD NON-PHARMACOLOGIC TREATMENT ● Rational management of children who are not relieved of their disability by medication rests on: | individual attention, frequent and consistent reward of socially acceptable behavior, consistent limit setting, and the gradual phasing in of material to be learned |
| ADHD NON-PHARMACOLOGIC TREATMENT ● In general, behavioral therapy: | should be an adjunct to effective stimulant therapy rather than the only treatment |
| ADHD PROGNOSIS 1 | ● Whereas the overt restlessness of hyperactive children diminishes in adolescence, their impulsiveness and emotional lability usually persist, with a correspondingly mixed prognosis for long-term adaptive outcome |
| ADHD PROGNOSIS 2 | ● Adults who had ADHD in childhood often continue to show functional impairment ● When aggressiveness is a feature, it particularly tends to persist and appears to bear some association with early onset alcoholism |
| ADHD PROGNOSIS 3 | ● Schizophrenia is not a major ADHD outcome. However, children of schizophrenic mothers, at high risk for adult schizophrenia, have been found to be prone to attentional dysfunction and poor social competence |
| OPPOSITIONAL DEFIANT DISORDER (ODD) 1 | ● Enduring patterns of negativistic, disobedient, and hostile behavior toward authority figures, and an inability to take responsibility for mistakes, leading to placing blame on others, but in the absence of serious violations of the rights of others |
| OPPOSITIONAL DEFIANT DISORDER (ODD) 2 | ● Frequently argue with adults and become easily annoyed by others, leading to a state of anger and resentment ● May have difficulty in the classroom and with peer relationships, but generally do not resort to physical aggression or destructive behavior |
| ODD PREVALENCE | ● Can begin as early as 3 yrs of age, but is typically noted by 8 yrs of age and usually not later than early adolescence ● males > females (1.4:1) prior to adolescence ● The prevalence in males and females diminishes in youth older than 12 yrs of age |
| ODD RISK FACTORS ● Temperamental | ○ Temperamental factors related to problems in emotional regulation (e.g., high levels of emotional reactivity, poor frustration tolerance) have been predictive of the disorder |
| ODD RISK FACTORS ● Environmental | ○ Harsh, inconsistent, or neglectful child-rearing practices are common in families of children and adolescents with oppositional defiant disorder, and these parenting practices play an important role in many causal theories of the disorder |
| ODD RISK FACTORS ● Genetic and physiological | ○ A number of neurobiological markers (e.g., lower heart rate and skin conductance reactivity; reduced basal cortisol reactivity; abnormalities in the prefrontal cortex and amygdala) have been associated with oppositional defiant disorder |
| ODD ETIOLOGY | ● Pathology begins when this oppositional behavior persists abnormally, authority figures overreact, or oppositional behavior recurs considerably more frequently than in most children of the same mental age ○ Normal at 18-24 months (terrible 2) |
| Irritability | appears to be the one most predictive of later psychiatric disorders, whereas the other elements may be considered components of temperament |
| ODD TYPES ● Angry/Irritable | ○ Often lose their tempers, are easily annoyed, and feel irritable much of the time ○ Can progress to CD |
| ODD TYPES ● Argumentative/Defiant | ○ Display a pattern of arguing w/ authority figures & adults ○ Children actively refuse to comply w/ requests, deliberately break rules, and purposely annoy others ○ Do not take responsibility for their actions, often blame others for their misbehavior |
| ODD TYPES ● Vindictive | ○ Vindictive or spiteful actions at least twice in 6 months to meet diagnostic criteria ○ Can progress to CD |
| ODD CLINICAL FEATURES 1 | ● Typically, symptoms of the disorder are most evident in interactions with adults or peers whom the child knows well |
| ODD CLINICAL FEATURES ● The symptoms of oppositional defiant disorder may be confined to: | only one setting, and this is most frequently the home |
| ODD CLINICAL FEATURES 2 | ● Chronic oppositional defiant disorder or irritability almost always interferes with interpersonal relationships and school performance ● These children are often rejected by peers, and may become isolated and lonely |
| ODD CLINICAL FEATURES 3 | ● Despite adequate intelligence, they may do poorly or fail in school, due to their lack of cooperation, poor participation, and inability to accept help ● Low self-esteem, poor frustration tolerance, depressed mood, and temper outbursts |
| ODD CLINICAL FEATURES 4 | ● Adolescents who are ostracized may turn to alcohol and illegal substances as a modality to fit in with peers ● Children who are chronically irritable often develop mood disorders in adolescence or adulthood |
| ODD Diagnostic Criteria A: | vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling |
| ODD Diagnostic Criteria A ● Angry/Irritable Mood | 1. Often loses temper 2. Is often touchy or easily annoyed 3. Is often angry and resentful |
| ODD Diagnostic Criteria A ● Argumentative/Defiant Behavior | 4. Often argues with authority figures and adults 5. Often actively defies or refuses to comply with requests from authority figures or with rules 6. Often deliberately annoys others 7. Often blames others for his or her mistakes or misbehavior |
| ODD Diagnostic Criteria A ● Vindictiveness | 8. Has been spiteful or vindictive at least twice within the past 6 months |
| ODD Diagnostic Criteria ● For children younger than 5 years | the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8). |
| ODD Diagnostic Criteria ● For individuals 5 years or older | the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8). |
| ODD Diagnostic Criteria B: | B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context, or it impacts negatively on social, educational, occupational, or other important areas of functioning |
| ODD Diagnostic Criteria C: | C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder |
| ODD Diagnostic Criteria ● Specify current severity: MILD | Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers) |
| ODD Diagnostic Criteria ● Specify current severity: MODERATE | Some symptoms are present in at least two settings |
| ODD Diagnostic Criteria ● Specify current severity: SEVERE | Some symptoms are present in three or more settings |
| ODD DIFFERENTIAL DIAGNOSIS ● Conduct Disorder | ○ ODD is less severe and has no destruction of people, animals, properties |
| ODD DIFFERENTIAL DIAGNOSIS ● ADHD | ○ Lose focus in attention in general ○ ODD just don’t want to conform |
| ODD DIFFERENTIAL DIAGNOSIS ● Mood Disorder | ○ Episodic |
| ODD DIFFERENTIAL DIAGNOSIS ● Disruptive Mood Dysregulation Disorder | ○ Severity and frequency of outbursts are more severe |
| ODD DIFFERENTIAL DIAGNOSIS ● Intermittent Explosive Disorder | ○ Serious aggression toward others |
| ODD DIFFERENTIAL DIAGNOSIS ● Intellectual Disability | ○ If oppositional behavior is comparable to those of the same age |
| ODD DIFFERENTIAL DIAGNOSIS ● Language Disorder | ○ Cannot follow because they don’t understand |
| ODD DIFFERENTIAL DIAGNOSIS ● Social Anxiety Disorder | ○ Fear of having negative evaluation |
| ODD COMORBIDITY | ● ADHD ● Anxiety Disorder ● Mood Disorder |
| ODD COURSE AND PROGNOSIS 1 | ● Oppositional defiant disorder often precedes the development of conduct disorder, especially for those with the childhood-onset type of conduct disorder |
| ODD COURSE AND PROGNOSIS 2 | ● Persistence of oppositional defiant symptoms poses an increased risk of additional disorders, such as anxiety disorders, mood disorders, conduct disorder and substance use disorders |
| ODD COURSE AND PROGNOSIS ● The defiant, argumentative, and vindictive symptoms | carry most of the risk for conduct disorder |
| ODD COURSE AND PROGNOSIS ● angry-irritable mood symptoms | carry most of the risk for emotional disorders |
| ODD COURSE AND PROGNOSIS ● Positive outcomes | are more likely for intact families who can modify their own expression of demands and give less attention to the child’s argumentative behaviors. |
| ODD COURSE AND PROGNOSIS ● In children who have a long history of aggression and oppositional defiant disorder | there is a greater risk of the development of conduct disorder and later substance use disorders |
| ODD COURSE AND PROGNOSIS ● Parental psychopathology, such as antisocial personality disorder and substance abuse | appears to be more common in families with children who have oppositional defiant disorder, which creates additional risks for chaotic and troubled home environments |
| ODD COURSE AND PROGNOSIS ● The prognosis for oppositional defiant disorder in a child depends somewhat | on family functioning and the development of comorbid psychopathology |
| ODD TREATMENT ● Primary treatment | Family intervention using both direct training of the parents in child management skills and careful assessment of family interactions |
| ODD TREATMENT ● Intervention goal | To reinforce more prosocial behaviors and to diminish undesired behaviors at the same time |
| ODD TREATMENT ● Cognitive behavioral therapists emphasize | Teaching parents how to discourage child’s oppositional behavior by diminishing attention to it, and encourage appropriate therapy focuses on selectively reinforcing and praising appropriate behavior and ignoring or not reinforcing undesired behavior |
| ODD TREATMENT ● In the therapeutic relationship | The child can learn new strategies to develop a sense of mastery and success in social situations with peers and families |
| ODD TREATMENT ● In the safety of a more “neutral” relationship | children may discover that they are capable of less provocative behavior |
| ODD TREATMENT ● Often, _________ must be restored before a child with oppositional defiant disorder can make more positive responses to external control | self-esteem |
| CONDUCT DISORDER (CD) | ● Children who develop enduring patterns of aggressive behaviors that begin in early childhood and violate the basic rights of peers and family members ● Associated with many other psychiatric disorders including ADHD, depression, and learning disorders |
| Youth with conduct disorder often demonstrate behaviors in the following four categories: | ○ Physical aggression or threats of harm to people ○ Destruction of own property or that of others ○ Theft or acts of deceit ○ Frequent violation of age-appropriate rules |
| CD PREVALENCE | ● Occurs with greater frequency in the children of parents with antisocial personality disorder and alcohol dependence than in the general population ● Associated with socioeconomic factors, as well as parental psychopathology |
| CD RISK FACTORS ● Temperamental | ○ Include a difficult undercontrolled infant temperament and lower-than-average intelligence, particularly with regard to verbal IQ |
| CD RISK FACTORS ● Environmental; Family-level risk factors include | ○ Parental rejection & neglect, inconsistent child-rearing practices, harsh discipline, abuse, lack of supervision, early institutional living, changes of caregivers, large family size, parental criminality, & certain kinds of familial psychopathology |
| CD RISK FACTORS ● Environmental; Community-level risk factors include | ○ Peer rejection, association with a delinquent peer group, and neighborhood exposure to violence |
| CD RISK FACTORS ● Genetic and physiological 1 | ○ The risk is increased in children with a biological or adoptive parent or a sibling with conduct disorder |
| CD RISK FACTORS ● Genetic and physiological 2 | ○ Also appears to be more common in children of biological parents with severe alcohol use disorder, depressive and bipolar disorders, or schizophrenia or biological parents who have a history of ADHD or conduct disorder |
| CD RISK FACTORS | ● Chronic exposure to violence in the media ● Slower resting heart rate ● Reduced autonomic fear conditioning, particularly low skin conductance ● Structural and functional differences in brain areas associated w/ affect regulation & affect processing |
| CD NEUROBIOLOGICAL FACTORS | ● Decreased gray matter in limbic brain structures, and in the bilateral anterior insula and left amygdala compared to healthy controls ● Neurotransmitter studies suggest low levels of plasma dopamine-hydroxylase ● High plasma serotonin levels in blood |
| CD NEUROBIOLOGICAL FACTORS ● EEG | ○ Aggressive children had significantly greater relative right frontal brain activity at rest compared with nonaggressive children |
| plasma dopamine-hydroxylase | an enzyme that converts dopamine to norepinephrine, leading to a hypothesis of decreased noradrenergic functioning in conduct disorder |
| CD CLINICAL FEATURES 1 | ● The onset may occur as early as the preschool years, but the first significant symptoms usually emerge during the period from middle childhood through middle adolescence ● The average age of onset of conduct disorder is younger in boys than in girls |
| CD CLINICAL FEATURES ● Boys most common age to meet diagnostic criteria | by 10-12 years |
| CD CLINICAL FEATURES ● Girls most common age to meet diagnostic criteria | reach 14-16 years before the criteria are met |
| CD CLINICAL FEATURES 2 | ● Aggressive antisocial behavior can take the form of bullying, physical aggression, and cruel behavior toward peers ● Children may be hostile, verbally abusive, impudent, defiant, and negativistic toward adults |
| CD CLINICAL FEATURES 3 | ● Persistent lying, frequent truancy, and vandalism are common. In severe cases, destructiveness, stealing, and physical violence often occur ● Sexual behavior and regular use of tobacco, liquor, or illicit psychoactive substances |
| CD CLINICAL FEATURES 4 | ● Suicidal thoughts, gestures, and acts are frequent in children and adolescents ● Some children with aggressive behavioral patterns have impaired social attachments ● Poor self-esteem, although they may project an image of toughness |
| CD CLINICAL FEATURES 5 | ● They lack the skills to communicate in socially acceptable ways and appear to have little regard for the feelings, wishes, and welfare of others ● Often feel guilt or remorse for some of their behaviors, but try to blame others to stay out of trouble |
| CD CLINICAL FEATURES 6 | ● In other cases, includes repeated truancy, vandalism, and serious physical aggression or assault against others by a gang, such as mugging, gang fighting, and beating |
| CD Diagnostic Criteria | ● A repetitive and persistent pattern of behavior in which the basic rights of others or ma-jor age-appropriate societal norms or rules are violated ● Manifested by the presence of at least three following 15 criteria in the past 12 months |
| CD Diagnostic Criteria ● Aggression to People and Animals | 2. Often initiates physical fights 3. Has used a weapon that can cause serious physical harm to others 4. Has been physically cruel to people 5. Physically cruel to animals 6. Stolen while confronting a victim 7. Forced someone into sexual activity |
| CD Diagnostic Criteria ● Destruction of Property | 8. Has deliberately engaged in fire setting with the intention of causing serious damage 9. Has deliberately destroyed others' property (other than by fire setting) |
| CD Diagnostic Criteria ● Deceitfulness or Theft | 10. Has broken into someone else's house, building, or car 11. Often lies to obtain goods or favors or to avoid obligations 12. Has stolen items of nontrivial value without confronting a victim |
| CD Diagnostic Criteria ● Serious Violations of Rules | 13. Often stays out at night despite parental prohibitions, beginning before age 13 years 14. Has run away from home overnight at least twice, or once without returning for a lengthy period 15. Is often truant from school, beginning before age 13 years |
| CD Diagnostic Criteria B: | B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning |
| CD Diagnostic Criteria C: | C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder |
| CD Diagnostic Criteria ● Specify whether: 312.81 (F91.1) Childhood-onset type | Individuals show at least one symptom char-acteristic of conduct disorder prior to age 10 years. |
| CD Diagnostic Criteria ● Specify whether: 312.82 (F91.2) Adolescent-onset type | Individuals show no symptom characteristic of conduct disorder prior to age 10 years. |
| CD Diagnostic Criteria ● Specify whether: 312.89 (F91.9) Unspecified onset | Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years. |
| CD Diagnostic Criteria ● Specify if: With limited prosocial emotions | To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. |
| CD Diagnostic Criteria ● Specify if: Lack of remorse or guilt | Does not feel bad or guilty when he or she does something wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. |
| CD Diagnostic Criteria ● Specify if: Callous–lack of empathy | Disregards and is unconcerned about the feelings of others. Described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others |
| CD Diagnostic Criteria ● Specify if: Unconcerned about performance | Does not show concern about poor/problematic performance at school, at work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others |
| CD Diagnostic Criteria ● Specify if: Shallow or deficient affect | Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions "on" or "of" quickly) or when emotional expressions are used for gain |
| CD Diagnostic Criteria ● Specify current severity: MILD | Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule-breaking) |
| CD Diagnostic Criteria ● Specify current severity: MODERATE | The number of conduct problems and the effect on others are intermediate between those specified in "mild" and those in "severe" (e.g., stealing without confront- ing a victim, vandalism) |
| CD Diagnostic Criteria ● Specify current severity: SEVERE | Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems that cause considerable harm to others |
| CD GENDER-RELATED DIAGNOSTIC ISSUES ● Males | ● with a diagnosis of conduct disorder frequently exhibit fighting, stealing, vandalism, and school discipline problems ● tend to exhibit both physical aggression and relational aggression |
| CD GENDER-RELATED DIAGNOSTIC ISSUES ● Females | ● with a diagnosis of conduct disorder are more likely to exhibit lying, truancy, running away, substance use, and prostitution ● tend to exhibit relatively more relational aggression |
| CD DIFFERENTIAL DIAGNOSES | ● Oppositional Defiant Disorder ● ADHD ● Mood Disorder ● Intermittent Explosive Disorder ● Adjustment Disorder |
| CD COMORBID FACTORS | ● ADHD and ODD ● Personality features associated with antisocial personality disorder ● Co-occur w/ one or more of the ff mental disorders: specific learning disorder, anxiety disorders, depressive or bipolar disorders, and substance-related disorders |
| CD COURSE AND PROGNOSIS | ● In a majority of individuals, the disorder remits by adulthood. ● The best prognosis is predicted for mild conduct disorder in the absence of coexisting psychopathology and the presence of normal intellectual functioning |
| CD COURSE AND PROGNOSIS ● The course and prognosis for children with conduct disorder is most guarded: | in those who have symptoms at a young age, exhibit the greatest number of symptoms, and the most severe, and express them most frequently. |
| ANTISOCIAL PERSONALITY DISORDER (ASPD) | A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years |
| ANTISOCIAL PERSONALITY DISORDER (ASPD) Diagnostic Criteria ● A. Indicated by three (or more) of the following: (1) | 1. Failure to conform to social norms w/ respect to lawful behaviors, indicated by repeatedly performing acts that are grounds for arrest 2. Deceitfulness, indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure |
| ANTISOCIAL PERSONALITY DISORDER (ASPD) Diagnostic Criteria ● A. Indicated by three (or more) of the following: (2) | 3. Impulsivity or failure to plan ahead 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults 5. Reckless disregard for safety of self or others |
| ANTISOCIAL PERSONALITY DISORDER (ASPD) Diagnostic Criteria ● A. Indicated by three (or more) of the following: (3) | 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another |
| ANTISOCIAL PERSONALITY DISORDER (ASPD) Diagnostic Criteria B: | B. The individual is at least 18 years old |
| ANTISOCIAL PERSONALITY DISORDER (ASPD) Diagnostic Criteria C: | C. There is evidence of conduct disorder with onset before 15 years |
| ANTISOCIAL PERSONALITY DISORDER (ASPD) Diagnostic Criteria D: | D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder |
| ASPD TREATMENT | ● Cognitive behavioral therapy |
| ASPD TREATMENT ● Atypical antipsychotics | ○ Risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify) ○ Side effects of second-generation antipsychotics |
| Side effects of second-generation antipsychotics include | sedation, increased prolactin levels, (with risperidone use) and extrapyramidal symptoms, including akathisia |
| ASPD TREATMENT ● Clonidine (Catapres) may decrease aggression | ○ Alpha 2 agonist |
| ASPD TREATMENT ● SSRIs | ○ Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa), are used clinically to target symptoms of impulsivity, irritability, and mood lability, which frequently accompany conduct disorder |
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avemaria