ADHD, ODD, CD Flashcards
What disorders are regularly co-morbid with ADHD?
ODD 20% to 30% CD 30% to 50% Anxiety 25% Depression 15-50% Learning disorder 10-90%
What is the history of ADHD?
Originally described as ‘defect in moral control’ (spiteful, lawless, jealous, dishonest, destructive, shameless, sexual immorality and viciousness)
At the end of WW1 there was minimal brain damage and attentional problems- so it was called Minimal Brain Damage disorder
Soon the behaviours continued but without evidence of brain damage, term changed to minimal brain dysfunction
DSM-III named it hyperkinetic reaction of childhood (didn’t talk about attention)
The next DSM-III added attention deficit
DSM-III-R replaced innattentive to undifferentiated adhd, the checklists were merged
DSM-5 : ADHD with 3 subtyped (predominately innatentive, predominatenyl hyperactive/impulsive, combined type)
Diagnostic criteria for ADHD
Inattention (6+) Makes careless mistakes Difficulty sustaining attention Doesn’t listen when spoken to Doesn’t follow instructions Difficulty organising tasks Avoids tasks requiring mental effort Loses things Easily distracted Forgetful Hyperactive/impulsive – at maladaptive levels for at least last 6 months (6+) Fidgets Leaves seat when required to sit Inappropriately runs or climbs Difficulty playing Often ‘on the go’ Talks excessively Bursts out answers Difficulty waiting turn Interrupts others
Extra conditions for diagnosis
Behaviours present before 12 yrs
In DSM-4 had to be present before the age of 7
Moved the age of onset older so that people could remember when making an adult diagnosis
Impairment present in 2 or more settings
Clear evidence of impairment (social, academic) + vocationally in adults
Does not exclusively occur during course of schizophrenia, other psychotic disorder
Consider this when assessing adults
Not better accounted for by other mental disorder (i.e. mental retardation)
Adam suggests running an IQ on almost everyone with behavioural concerns, to see if there are problems of mental retardation
Prevalence of ADHD
ADHD is the most common childhood psychiatric disorder in clinical practice.
5-9% prevalence
More common in males
Hyperactivity is more likely to present as hyper-talkativeness in females
ADHD in adults
40-60% childhood sufferers have ADHD as adults
Hyperactivity often decreases, but impulsivity and innattention remains
ADHD and psychosis
Preliminary studies suggest that childhood ADHD may be a precursor to adult psychosis
Maturational lag hypothesis
ADHD is marked by slower development of the central nervous system
This model doesn’t work for inattention, only hyperactivity
Cortical hypoarousal model
CNS is underaroused (hence why stimulants work)
Hyperactivity is an attempt to increase sensory input to normal levels
This model still holds
Inhibitory deficit model/executive function deficit model
Inhibition deficit is primary, there are impaired executive functions (working memory, self regulation of affect, motivation, arousal) and motoric control problems
Cognitive energetic model
Efficacy of information processing is determined by the interplay of attention, state factors and management/executive function.
Attention includes: encoding, search, decision making and motor organisation.
State factors include; effort, arousal and activation
Arousal is a tonic measure, activation is a phasic measure
EF’s: planning monitoring, detection of errors, error correction
All 3 levels interact to form deficits in ADHD
ADHD Medication
Medication is by far the most effective, and stimulants work for 80+% of children
Methylphenidate Hydrochloride: Ritalin, Ritalin LA, Concerta, Attenta
mode of action in humans is not completely understood, but methylphenidate presumably exerts its stimulant effect by activating the brainstem arousal system and cortex
Increases dopamine in the synaptic cleft
Dexamphetamine (cheaper than Ritalin)
Atomoxetine hydrochloride: Strattera, inhibitor of the presynaptic noradrenaline transporter- A non-stimulant which means that it is less controlled in most countries
Clonidine Hydrochloride : hypertensive, used to help with sleep and conduct disorder
Neurofeedback
Aims to normalise abnormal brain activity in children
Conducted as continuous feedback or using operant conditioning principals to normalise brainwave activity
Mixed results in the literature
Randomised controlled double blinded trials showed no benefit of neurofeedback vs placebo
ADHD and diet
Will aid approx 5% of children with ADHD
Elimination died
ADHD: Behaviour modification and therapy
Positive reinforcement does work
Family therapy: doesn’t fix core symptoms but will work for associated problems
Cognitive therapies: will do nothing for core symptos, but can treat peripheral problems again
ODD diagnostic criteria
A recurrent pattern of negativistic, defiant, disobedient and hostile behaviour towards authority figures that persists for 6 months and is characterised by at least 4 of the following:
Often loses temper
Is often touchy or easily annoyed
Is often angry and resentful
Often argues with authority figures or for children with adults
Often actively defies or refuses to comply with adults requests or rules
Often deliberately annoys others
Often blames others for his or her mistakes or misbehaviours
Has been spiteful or vindictive at lease twice within the past 6 months
ALSO this behaviour causes empairmens
ALSO it does not eccur during the course of psychotic or mood disorders
MILD, MOD, SEVERE specifiers
ODD associated features
Usually behave poorly with those they know, not so much psychologists
In situations where the child is looked after by a succession of caregivers
In families who use harsh, inconsistent or neglectful childrearing practices.
More common in families in which one parent had history of mood disorders, ODD, CD, ADHD, Antisocial personality disorder or substance abuse
More common in families with serious marital discord
Development of ODD
Uusally evident before 8 years, and not later than adolescence
Oppositionality naturally occurs in pre-schoolers and adolescence so make sure to check age appropriateness of behaivour
Prevalence of ODD
2-16% of children
Conduct disorder (CD)
Repetitive and persistent pattern of behaviour in children and adolescents in which the rights of others or basic social rules are violated
DSM criteria for CD
3 or more criteria over the last 12 months:
Aggression to people and animals
bullies, threatens or intimidates others
often initiates physical fights
has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun)
is physically cruel to people or animals
steals from a victim while confronting them (e.g. assault)
forces someone into sexual activity
DESTRUCTION OF PROPERTY: sets fire, destroys property
DECEITFULNESS, LYING OR STEALING: broke into someones house, or car, lies to obtains goods, steals items i.e. shoplifting
SERIOUS VIOLATION OF RULES: stays out at night despite parental objections, runs away from home, truant from school
_The disturbance is impairing social, academic and occupational funcitoning
- Does not meet criteria for antisocial personality disorder if over 18 years
SPEFICIERS: if child, onset of at least on criteria prior to age 10
Asolescent type, absence of any criteria prior to age 10
MILD, MOD, SEVERE
Rarely occurs over ge of 18, more prevalent in males than remales
CD Interventions
Medication: can alleviate symptoms but won’t cure: Simulants (ritalin ect, not a good idea), Antidepressants (prozac), anticonvulsants (Dilantin, Tegretol), Lithium, Clonidine (Catapres)
Role model: get a role model that’s an adult
Behaviour modification: Target problem behaviours with strategies like time out, principles of reward/punishment, don’t cover all problems decide which ones are most important, and give parents time out to themselves, Reward the behaviours you want DON’T punish beaviours you don’t want
Anger management: punching bag, or physical sport
Parenting styles
Authoritarian (do it because I said)
Authoritative (give reason why they should act in such a way)
Submissive (let child do whatever they’d like)
Parent training for OD
Teach parents how to be authoritative, limit the childs freedom
Parent therapy for OD
Biggest problems are: inconsistent parenting, punitive punishment, neglect and abuse
Kohlberg Moral Development
Stage 1. Heteronomous morality
Act to avoid punishment, obedience for its own sake.
Stage 2. Individualism
Only follow rules when in persons immediate interest.
Stage 3. Mutual interpersonal expectations
Living up to what is expected by other people close to you.
Stage 4. Social system and conscience
Laws are to be upheld except in extreme cases where they conflict with fixed social duties.
Stage 5. Social contract and individual rights
The law should be upheld as it is the fabric of society, as long as it supports fundamental human rights.
Stage 6. Universal ethical principals
Person follows self chosen ethical principals. Laws are often based in these, but when not, ethical principals override the law.
