Disruptive Behaviour

Disorders
Donna Dowling
Child & Adolescent Psychiatrist
Townsville CAYAS

 ADHD (= ADD)
Oppositional Defiant
Disorder
Conduct Disorder

Epidemiology

Epidemiology
Around 3-5% of schoolchildren display
ADHD, as many as 90% of them boys
Worldwide studies consistent not just
western disease
Many children show a lessening of
symptoms as they move into adolescence
At least half continue to have problems
One-third of those affected have symptoms
into adulthood

Aetiology

Aetiology
Heritability is the strongest factor in
development of ADHD
Risk factors account for only a small portion of
variance

Pregnancy variables: young maternal age,

maternal use of tobacco and alcohol, toxaemia,
post-maturity and extended labour
Medical factors: fragile X syndrome, G6PD
deficiency, phenylketonuria, brain trauma, lead
poisoning, malnutrition

Main Neurotransmitters in ADHD

Dopamine
Noradrenaline
To regulate the inhibitory influences
in the frontal-cortical processing of
information

Dopamine

- enhances signals
- improves:
. attention,
. focus vigilance,
. acquisition,
. on-task behaviour and cognition

Noradrenaline
dampen noise
decrease distractibility and shifting
improve executive operations
increase behavioural, cognitive,
motoric inhibition

Aetiology
ADHD symptoms and a diagnosis of ADHD may
themselves create interpersonal problems and
produce additional symptoms in the child

Some children sensitive to

colourings/preservatives not sugar per se

Diagnosing ADHD

Inattention symptoms
Fails to give close attention; careless mistakes
Difficulty sustaining attention in tasks or play activities =
requires frequent redirection
Does not seem to listen when spoken to directly
Does not follow through on instructions; fails to finish task
(not oppositional or failure to understand
Difficulty organizing tasks = homework poorly organized
Dislikes sustained mental effort = schoolwork; homework
Loses possessions
Easily distracted
Forgetful
Daydreams
Can be very quiet & missed

Hyperactivity

Fidgets; squirms
Leaves seat when expected to sit
Runs or climbs excessively
Difficulty in playing quietly
Often "on the go" or acts as if "driven by a motor"
Often talks excessively
Perceived immature
Accidents/injuries prone

Impulsivity
blurts out answers before questions
completed
difficulty waiting turn
interrupts or intrudes on others

Impatient
Rushing into things
Risk taking; Taking dares

DSM IV Criteria
A:

6 / 9 inattention
&/or
6 / 9 hyperactivity & impulsivity
= 6 months; maladaptive & inconsistent with development level

B: symptoms before age of 7

C: impairment in 2 settings
D: clinically significant social/academic
E: not better explained by something else

Assessment
History parents or caregivers,

as well as a classroom teacher or other

school professional

Interview of child
Parent and teacher ratings of ADHDrelated behaviours
Investigations - No clinical examination or lab
tests are accepted as either rule in or rule
out. Recommend vision & hearing tested

Assessment

RATING SCALES
- Not diagnostic screening test
- Monitor response to interventions

PSYCHOMETRICS
- WISC/WIAT

- CPT

- TEA-Ch

Others as indicated
-

Speech & language

Occupational therapy
Auditory processing

Differential Diagnosis

Differential
Diagnosis
Hearing Loss
Auditory
processing
Learning Disability
Epilepsy
CNS abnormality
Metabolic

Tourettes
syndrome
Tics
Sleep apnoea
Lead poisoning
Hyperthyroidism
Pin worms
Autism

Differential
Diagnosis
Bipolar
Disorder
Anxiety
Disorder
Substance
Abuse
Depression

Emotional
distress
PTSD
Oppositional
Defiant
Disorder
Conduct
Disorder

LD VS. ADHD

Lacks early childhood history of hyperactivity

ADHD behaviours arise in middle childhood

ADHD behaviours appear to be task- or
subject-specific
Not socially aggressive or disruptive
Not impulsive or disinhibited

ADHD VS. ANXIETY

DISORDERS

Not overly concerned with competence

Not anxious or nervous
Exhibit little or no fear
Have no difficulty separating from parents
Infrequently experience nightmares
Inconsistent performance
Not concerned with future
Are not socially withdrawn
May be aggressive
May be able to pay attention if work is
stimulating

DEPRESSION VS. ADHD

Not usually as active
Marked changes in affect/mood
Concentration problems have acute
onset possibly following stress event
Changes in eating and sleeping habits
Loss of interest or pleasure in most
activities

ODD/CD VS. ADHD

Lacks impulsive, disinhibited
behaviour
Able to complete tasks requested by
others
Resists initiating response to
demands

ODD/CD VS. ADHD

Lacks poor sustained attention and
marked restlessness
Often associated with parental child
management deficits or family
dysfunction

Child abuse victims are at

increased risk of a variety of child
and adolescent psychiatric
diagnoses, including depression,
anxiety, conduct disorders, ODD,
ADHD and substance abuse.
Kaplan et al Oct 1999

Comorbidity

Comorbidity
Substance
Abuse

O.C.D.

O.D.D.

Dyspraxia

C.D.

A.D.H.D.

Sleep
Disorders

Bipolar
Disorder

Speech &
Language
Anxiety/
Depression Aspergers
Syndrome

Dyslexia
Tics/
Tourettes

As many as one-third of
children diagnosed with
ADHD also have a coexisting condition.

Comorbidity
NEURO- DEVELOPMENTAL

learning disorders
language disorders
cognitive impairment
functionally significant soft
neurological features

Comorbidity
EMOTIONAL-BEHAVIORAL
lowered self esteem
downward cycle
school failure
substance abuse
antisocial behaviour
violence

Comorbidity
Conduct problems (e.g., oppositional
behaviour, lying, stealing, and fighting)
Mood or anxiety problems

Academic underachievement
Specific learning disabilities
Peer relationship problems

Impact

Impact
Emotional
Low self esteem
Impaired self-regulation
Relationship difficulties
Cognitive
Organizing; planning and time management
Learning delay
Short term memory problems; lack of focus
Language/speech
Physical
Fine & gross motor skill delay

Behaviour
Impaired self-regulation

Impact
Pervasiveness of symptoms
Persistence of symptoms
Associated problems:

Aggression
Psychosocial dysfunction: peers, family
Poor academic achievement
Drug or alcohol use
Criminal activity

Impact

Good family support

Higher intelligence
Good peer relationships
Positive temperament, nonaggressive
Emotional health, positive selfesteem
Socio-economic factors
Diminution or resolution of symptoms

Impact
32-40% of students with ADHD drop out of
school
Only 5-10% will complete college
50-70% have few or no friends
70-80% will under-perform at work
40-50% will engage in antisocial activities
More likely to experience teen pregnancy &
sexually transmitted diseases
Have more accidents & speed excessively
Experience depression & personality disorders
(Barkley, 2002)

School difficulties & ADHD

High rates of disruptive behaviour
Low rates of engagement with academic
instruction and materials
Inconsistent completion and accuracy on
schoolwork
Poor performance on homework, tests, &
long-term assignments
Difficulties getting along with peers &
teachers

Life Impairments
Childhood
Academic and social issues

Adolescence
Substance abuse, driving accidents
Teen pregnancies, dont finish school

Young Adults
Poor job stability, disrupted marriages
Financial difficulties, impulsive crimes

Management

Psychological
Psychiatric

Educational

Behavioural &
parent training
programmes

Substance
abuse

Multidisciplinary
Management of ADHD
Coaching

Dietary

Medical

Other
individually
determined
strategies

Management
Psychoeducational
Family; School

Environmental
dietary modifications
parenting

Academic skills training

Psychological
Cognitive; Behavioural

Medication

Non-Pharmacological Management
Family Therapy may be required for
reasons such as: difficulty raising &
managing a child with ADHD and new
roles for individuals within the family.
ADHD in parents may impact success of
parent training and family therapy

Non-Pharmacological Management
Diet
Elimination diets difficult
Omega 3 at least 1000mg/day for a month

Academic skills training: focus on following

directions, becoming organized, using time
effectively, checking work, taking notes

Non-Pharmacological Management
Behavioural therapy
- Does not reduce symptoms
May improve social skills and compliance
Does not lead to maintenance of gains or
improvement over time after the therapy is
completed
Social skills group
- Uses modelling, practice, feedback and
contingent reinforcement to address the social
deficits common in children with ADHD
- Useful for the secondary effects of ADHD,
such as low self-esteem, but not helpful for
core symptoms of ADHD

MEDICATIONS FOR ADHD

Stimulant Medications
Methylphenidate (Ritalin, Ritalin
LA, Concerta)
Dexamphetamine
Non-stimulant
Atomoxetine (Strattera)
Other
Clonidine (Catapres)
Risperidone (Risperdal)

MEDICATIONS FOR ADHD

Tricyclic Antidepressants
Desipramine ;Imipramine
(Tofranil)
Other Antidepressants
Bupropion (Zyban); Fluoxetine
(Prozac)

Stimulants
Used to treat ADHD since 1960s
200 placebo controlled studies over 40
years
Best studied and most frequently
prescribed
Precise mechanism of action not known
Blockade of pre-synaptic dopamine
transporter
Beneficial effects seen almost immediately

Stimulants

Methylphenidate:
Ritalin 10mg (3-4 hours)
Ritalin LA 20/30/40 mg (6-8 hours)
Concerta 18/36/54 mg(10-12 hours)
Amphetamine:
Dexamphetamine 10 mg (3-4 hours)

Stimulants Specific Effects

Improved sustained attention

Reduced distractibility
Improved short-term memory
Reduced impulsivity
Reduced motor activity
Decreased excessive talking
Reduced bossiness and aggression
with peers

Stimulants Specific Effects

Increased amount & accuracy of academic work
completed
Decreased disruptive behaviour
Improved handwriting and fine motor control
Reduced off-task behaviour in classroom
Improved ability to work and play independently as
many as 75% of kids on these medications show
improvement
also seems to cause improvement in kids without
ADHD in terms of attention and classroom behaviour

Stimulants
Not the only treatment needed, but
effective in 75-90% of ADHD cases
(7 through adult years).
Side effects few, rarely serious,
usually manageable.
Response to stimulants is NOT
diagnostic of ADHD

Stimulants

Effective during school and homework-time

Out of the system by bedtime
May use Monday to Friday or 7 days /week
Weekend use if significant behavioural
comorbidity or needed for weekend activity:
Theoretical: could worsen epilepsy
Not addictive
Use does not predispose to subsequent
substance abuse protective

SIDE EFFECTS OF STIMULANTS

Insomnia
Decreased Appetite (in 50-60%)
=>Weight Loss
1-2 cm shorter by end of growth
Headaches
Stomach aches (20-40%)
Mood lability/dysphoria
Prone to Crying (10%) sensitive

SIDE EFFECTS OF STIMULANTS

Nervous Mannerisms (10%)
Tics (<5%) and Tourettes (Very
Rare) - possible exacerbation or
uncovering of tics
Over focused behaviour; Cognitive
toxicity
(Mild) Increases in Heart Rate and
Blood Pressure
- NO INCREASE IN SUDDEN DEATH

Atomoxetine (Strattera)
Potent pre-synaptic, noradrenergic
transport blocker with low affinity for other
neurotransmitters
Structurally similar to Fluoxetine
Metabolized by CYP 2D6 system
Half-life = 4-5 hours
Optimal effects seen at 2 weeks

Atomoxetine (Strattera)
May be given as single daily dose
or bd
Dispensed in a capsule that cannot
be opened
Superior to placebo, but no good
data comparing efficacy to
stimulants yet exists

Atomoxetine - Indications
Severe side effects to
Methylphenidate/Dexamphetamine
weight loss; insomnia
If comorbidity anxiety & mood
disorders; tics; substance abuse

Atomoxetine (Strattera)
Adverse effects ~ 5%

Sedation
Nausea and vomiting
Decreased appetite
Modest increase in pulse and blood pressure
Irritability, mood swings
Fatigue
Urinary hesitancy/prostatism (3%)
Suicidal ideation

Atomoxetine (Strattera)
Suicidal Ideation black box
warning

2200 in study; 1300 on Strattera

5 reported suicidal thoughts
No deaths

Treatment Implications
More formulations now exist, use of
which involves the art of medicine.
Individualize medication for target
symptoms, target times
Stimulants outperform non-drug
interventions but combination (drug &
non-drug therapy) is best and permits
lower drug doses.

Hyperactivity and impulsivity

are among the most important
personality or individual
difference factors that predict
later delinquency.
Farrington 1996

Disruptive Behaviour
Disorders
OPPOSITIONAL DEFIANT DISORDER
Characterized by repeated arguments
with adults, loss of temper, anger, and
resentment
Children with this disorder ignore adult
requests and rules, try to annoy people,
and blame others for their mistakes and
problems
Between 2 and 16% of children will
display this pattern

Disruptive Behaviour
Disorders
CONDUCT DISORDER violate
rights of others
Aggression to people / animals
Conduct causing property loss or
damage
Deceitfulness or theft
Serious rule violation

Disruptive Behaviour
Disorders
Cases of conduct disorder have been
linked to genetic and biological
factors, drug abuse, poverty,
traumatic events, and exposure to
violent peers or community violence
They have most often been tied to
troubled parent-child relationships,
inadequate parenting, family conflict,
marital conflict, and family hostility

Disruptive Behaviour
Disorders
Because disruptive behaviour
patterns become more locked in with
age, treatments for conduct disorder
are generally most effective with
children younger than 13
Given the importance of family
factors in this disorder, therapists
often use family interventions

Disruptive Behaviour
Disorders
Sociocultural approaches such as
residential treatment programs have
helped some children
Individual approaches are sometimes
effective as well, particularly those that
teach the child how to cope with anger
Recently, the use of drug therapy has been
tried
Institutionalization in juvenile training
centres has not met with much success and
may, in fact, increase delinquent behaviour

Disruptive Behaviour
Disorders
It may be that the greatest hope for
reducing the problem of conduct
disorder lies in early intervention
programs that begin in early
childhood.
These programs try to change
unfavourable social conditions before a
conduct disorder is able to develop.

The latest analyses from the Dunedin

longitudinal study show hyperactivity
in combination with CD or CD
symptoms is clearly the most important
risk factor for becoming a serious
persistent offender in adulthood.
Prof T Moffitt, Maudsley Hospital