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Disruptive Behaviour Disorders

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

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Disruptive Behaviour Disorders

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  1. Disruptive Behaviour Disorders Donna Dowling Child & Adolescent Psychiatrist Townsville CAYAS

  2. ADHD (= ADD) • Oppositional Defiant Disorder • Conduct Disorder

  3. Epidemiology

  4. 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

  5. Aetiology

  6. 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

  7. Main Neurotransmitters in ADHD • Dopamine • Noradrenaline To regulate the inhibitory influences in thefrontal-cortical processing of information

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

  9. Noradrenaline • dampen « noise » • decrease distractibility and shifting • improve executive operations • increase behavioural, cognitive, motoric inhibition

  10. 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

  11. Diagnosing ADHD

  12. 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

  13. 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

  14. Impulsivity • blurts out answers before questions completed • difficulty waiting turn • interrupts or intrudes on others Impatient Rushing into things Risk taking; Taking dares

  15. 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

  16. Assessment • History – parents or caregivers, • as well as a classroom teacher or other school professional • Interview of child • Parent and teacher ratings of ADHD-related behaviours • Investigations - No clinical examination or lab tests are accepted as either “rule in” or “rule out.” Recommend vision & hearing tested

  17. 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

  18. Differential Diagnosis

  19. Hearing Loss Auditory processing Learning Disability Epilepsy CNS abnormality Metabolic Tourette’s syndrome Tics Sleep apnoea Lead poisoning Hyperthyroidism Pin worms Autism Differential Diagnosis

  20. Emotional distress PTSD Oppositional Defiant Disorder Conduct Disorder Bipolar Disorder Anxiety Disorder Substance Abuse Depression Differential Diagnosis

  21. 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

  22. 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

  23. 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

  24. ODD/CD VS. ADHD • Lacks impulsive, disinhibited behaviour • Able to complete tasks requested by others • Resists initiating response to demands

  25. ODD/CD VS. ADHD • Lacks poor sustained attention and marked restlessness • Often associated with parental child management deficits or family dysfunction

  26. “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

  27. Comorbidity

  28. Comorbidity O.C.D. Substance Abuse O.D.D. C.D. ‘Dyspraxia’ A.D.H.D. Bipolar Disorder Sleep Disorders Speech & Language ‘Dyslexia’ Tics/ Tourettes Anxiety/ Depression Asperger’s Syndrome

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

  30. NEURO- DEVELOPMENTAL learning disorders language disorders cognitive impairment functionally significant ‘soft’ neurological features Comorbidity

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

  32. Comorbidity • Conduct problems (e.g., oppositional behaviour, lying, stealing, and fighting) • Mood or anxiety problems • Academic underachievement • Specific learning disabilities • Peer relationship problems

  33. Impact

  34. 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

  35. Impact • Pervasiveness of symptoms • Persistence of symptoms • Associated problems: • Aggression • Psychosocial dysfunction: peers, family • Poor academic achievement • Drug or alcohol use • Criminal activity

  36. Impact • Good family support • Higher intelligence • Good peer relationships • Positive temperament, nonaggressive • Emotional health, positive self-esteem • Socio-economic factors • Diminution or resolution of symptoms

  37. 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)

  38. 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

  39. Life Impairments • Childhood • Academic and social issues • Adolescence • Substance abuse, driving accidents • Teen pregnancies, don’t finish school • Young Adults • Poor job stability, disrupted marriages • Financial difficulties, impulsive crimes

  40. Management

  41. Psychological Psychiatric Educational Behavioural & parent training programmes Substance abuse Multidisciplinary Management of ADHD Other individually determined strategies Coaching Dietary Medical

  42. Management • Psychoeducational • Family; School • Environmental • dietary modifications • parenting • Academic skills training • Psychological • Cognitive; Behavioural • Medication

  43. 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

  44. 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

  45. 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

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