ADHD, ODD

Question 1

Phases of Infant Attachment

Answer 1

• Asocial phase (0-6weeks)
• Indiscriminate phase (6weeks - 7months)
• Specififc attachment (7-9months)
• Multiple attachments (by 18 months)

Question 2

Oppositional Defiant Disoder

Answer 2

• Pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness ≥ 6months evidenced by ≥4 symptoms in any of the following categories and exhibited during interaction with one individual who is not a sibling.
• Disturbance is associated with distress in individual or in others in social circle, or it negatively impacts functioning
• Behaviours don’t occur exclusively during course of a psychotic, substance use, depressive, or bipolar. Also, does not meet critieria for disruptive mood dysregulation disorder
• *Behaviours may only be seeen in one setting (typically at home), but multiple settings indicates a greater severity. ODD is more common when parenting is harsh, inconsistent, or neglectful. Onset tends to be in preschool and preceds conduct disorder.

Question 3

Intermittent Explosive Disorder

Answer 3

• Recurrent behavioural outbursts representing failure to control aggressive impulses. Manifested by either of the following:
  
  • Verbal aggression or physical aggressive towards propery, animals, or other individuals. Occuring twice weekly on average for 3 months. Physical aggressive does NOT result in damage or destruction of property and does not result in physcial injury to animals or people.
  • 3 behavioural outburts involving damage or destruction of property and/or physical assault involving phsycial injury against animals or other individuals occuring within a 12 month period.
• Magnitude of aggressiveness expressed during the recurrent outburst is grossly out of proportion of provocation or to any percipitating psychosocial stressors
• Recurrent aggressive outburts are not premediated and are not comitted to achieve a tangible objective
• Causes distress in individual or functional impairment, or is associated wit financial or legal consequences
• Chronological age ≥6
• Not better explained by another mental disorder, medical condition, or substance.
• *Diagnosis should not be made is aggressive outburts seem to occur in context of an adjustment disorder

Question 4

Conduct Disoder

Answer 4

• Repetitive and persistent pattern of behaviour in which the basic right of others or major age-appropriate societal norms or rules are violated, as manifested by presence of 3/15 symptoms in the past 12 months, with at leat one criteria present in the past 6 months
  
  • Aggression to people or animals
  • Destruction of property
  • Deceifulness or theft
  • Serious violations of rules
• Causes impairment in functioning
• If individual is ≥ 18, criteria for antisocial personality disorder cannot be met

Question 5

Treatment for ODD and CD

Answer 5

• Children ≤ 8
  
  • Parent management training (PMT) - focuses on teaching parents better means of dealing with childs deviant behaviour and how to promote more appropriate behaviour. This also helps parents resolve disagreements on how to handle their child.
  • Cognitive problem-solving training (CPSST) - individual treatment. Aims to teach children how to handle interpersonal conflict and confrontation.
  • *Combination of both therapies tends to led to better results.
• Children > 8
  
  • Brief strategic family therapy - goal is to modify family interactions
  • Multisystemic therapy - goal is to increase family communication, parenting skills, and peer relationships
  • Cognitive behavioural therapy

Question 6

Attention-Deficit/Hyperactivity Disorder

Answer 6

• Persistent pattern of inattention and/or hyperacitivty-impulsivity that interferes with functioning or development, as characterized by 1 and/or 2
  1. Inattention - 6 or more of the following last ≥ 6 months to degree inconsistent with developmental level that nevgatively impacts functioning
• Fails to give close attention to details or makes careless misakes
• Difficulty sustaining in tasks or play activities
• Does not seem to listen when spoken to directly
• Does not follow through on instruction and fails to finish schoolwork, chores, or work responsibilities
• Difficulty organizing tasks and activities
• Avoids, dislikes, or is reluctant to engage in taks requiring sustained mental effort
• Often loses things necessary for tasks or activities
• Easily distracted by extraneous stimuli
• Often forgetful in daily activities

2. Hyperactivity and implusivity - 6 or more of the following lasting ≥ 6 months to degree inconsistent with developmental level that negatively impacts functioning

• Often fidgets with or taps hands or feeds or squirms in seat
• Offten leaves seat in situations where remaining seated in required
• Often runs about or climbs in inappropriate situations (adults-feeling restless)
• Unable to play or engage in leisure activities quietly
• Is often “on the go”
• Often talks excessively
• Often blurts out answer before question has been completed
• Has difficulty waiting turn
• Often interrupts or intrudes others

• Several symptoms were present prior to 12

• Several symptoms are present in 2 or more settings
• Clear evidence that symptoms interfere with, or reudce quality of functioning
• Symptoms don’t occur exclusively during course of schizoprenia and are not better explained by another mental disorder

Question 7

Treating aggression in youth with ADHD

Answer 7

• Psychostimulants have moderate-to-large effect on oppositinal behaviour, conduct problems, and aggression in youth with ADHD with or without ODD or CD
• Moderate evidence that quanfacine has a small-to-moderate effect on oppositional behaviour in children with ADD, with and without ODD
• High-quality evidence that atomoxetine has small effect on oppositional behaviour in children with ADD, with and without ODD

Question 8

Treating aggression in youth with ODD or CD, with and without ADHD

Answer 8

• High-quality evidence that risperidone has moderate effect on disruptive and aggressive behaviour
• Evidence suporting use of other antiopsychotics and mood stabilizers for this purpose is of low quality
• *Due to potential side effects and similar effect size, psychotherapy should be first line

Question 9

Treatment ADHD non-pharm

Answer 9

• Environment - children with ADHD have 2-5X increase risk of accidental injuries with ODD exacerbating this. Medication alone does not decrease these risks, showing importance of increased parental supervision - promote safety in home, authorative parenting, creation of structure.
• Enhance self esteem and build childs confidence - promote the childs strengths to help them develop resilience
• Behavioural - social skills training, anger management, parent training
• Educational - academic organization and study skills, specific acedemic remediation
• Psychological - CBT, IPT, family therapy
• Lifestyle - proper nutrition, good sleep hygiene, regulation exercise, extracurricular activities

Question 10

Pharmacological Treatment ADHD

Answer 10

• First line
  
  • Adderall XR - start at 5-10mg increasing by 5mg/week up to 30mg
  • Biphentin - start at 10-20mg increasing by 5-10mg/week up to 60mg
  • Concerta - start at 18mg increasing by 9-18mg/week up to 72mg
  • Vyvanse - start at 20-30mg increasing by 10mg/week up to 60mg
• Second line
  
  • Strattera - start at 0.5mg/kg/day increasing to 0.8-1.2mg/kg/day a week up to 1.4mg/kg/day or 60mg/day (lesser). Indicated as monotherapy or adjunctive (off label).
  • Intuniv XR (guanfacine) - start at 1mg increasing by 1mg/week up to 4mg. Indicated as monotherapy and adjective
  • Short-acting and intermediate acting preparations - use P.R.N for certain acitivities and to augments long-acting early or late in fay
    
    • To augment adderal XR or Vyvanse - short or intermediate acting dextro-ampetamine
    • To augment Biphentin or Concerta - short acting MPH products can be used b.i.d and T.i.d (Ritalin and Ritalin SR).