Disruptive, Impulse-Control and Conduct Disorders; Neurodevelopmental Disorders

Question 1

ADHD

Answer 1

• two subcategories: (1) inattention and (2) hyperactivity and impulsivity
• begins in childhood, associated = ODD, conduct disorder, specific learning disorder; 5% children and 2.5% of adults
• RF: VLBW (<1500g), smoking during preg, first degree relative, M (2x) > F
• hx: may include abuse, neglect, mult foster placements, lead exposure, enceph, alc exposure in utero, several inattentive or hyperactive impulsive sxs present PRIOR to age 12 (motoric hyperactivity in preschool, inattention more in elementary, hyperact less common in adolescence, impulsivity remains problematic in adulthood)
  
  • several sxs present in 2 or more settings (home, school, work; with friends or relatives), sxs interfere with or reduce quality of social, academic, or occupational fn, do not occur exclusively during course of schizophrenia or another psychotic/mental disorder
• prognosis: inc risk suicide attempt (when comorbid mood, conduct, or substance use disorders)

Question 2

ADHD inattention

Answer 2

• 6 or more of following for at least 6mo:
  
  • no close attention to detail or makes careless mistakes at school, work, etc.
  • difficulty sustatining attention in tasks or play activities
  • doesn’t seem to listen when spiken to directly
  • doesn’t follow through on instructions, fails to finish homework, chores, or duties in workplace
  • difficulty organizing tasks and activities
  • avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
  • often loses things necessary for tasks or activities
  • often distracted by extraneous stimuli
  • forgetful in daily activities

Question 3

ADHD hyperactivity and impulsivity

Answer 3

• 6 or more of the following for at least 6mo:
  
  • fidgets, taps hands/feet or squirms
  • leaves seat in situations when remaining seated is expected
  • runs about or climbs in situations where inappropriate
  • often unable to play or engage in leisure activities quietly
  • often “on the go” or “driven by a motor”
  • talks excessively
  • blurts out answers before question has been completed
  • difficulty waiting for his/her turn
  • interrupts or intrudes on others

Question 4

ADHD tx

Answer 4

• stimulants, nonstimulants, antidepressants, antihypertensives, modafinil
  
  • methylphenidate (ritalin, concerta, metadate) - can cause growth retardation, psychosis
  • amphetamine
  • antihypertensives more effective for hyperactivity and impulsivity - clonidine, guanfecine

Question 5

conduct disorder

Answer 5

• mostly male, 2-10% prevalence, comorbidities = ADHD, ODD, learning disorders, 90% of children with conduct disorder have had ODD
• sxs: patient violates basic rights of others
  
  • at least 3 of the 15 criteria in past 12mo w/ at least 1 in last 6mo:
    
    • aggression to people and animals; bullies, threatens, intimidates others; initiates physical fights; used a weapon that cuases harm to others; physically cruel to people or animals; stolen while confronting a victim; forced someone into sexual activity; destruction of property; engaged in fire-setting with intention of causing damage; deliberately destroyed others’ property; deceitfulness or theft; broken into house, building or car; lies to obtain goods or favors or to avoid obligations; stolen items of nontrivial value without confronting victim; serious violations of rules; stays out at night despite parental prohibitions; runs away from home overnight at least 2x while living in home or once without returning for lengthy period; truant from school

Question 6

oppositional defiant disorder (ODD)

Answer 6

• precursor to conduct disorder, prevalence = 1-11%, M>F, average age of onset 6yo
• comorbidities: anxiety, depression, substance use disorder
• sxs: pattern of angry/irritable mood, argumentative or defiant behavior, or vindictiveness lasting at least 6mo with at least 4 sxs:
  
  • angry or irritable mood; loses temper, touchy or easily annoyed, angry and resentful; argumentative and defiant behavior; argues with authority figures, actively defies rules or refuses to comply with requests; deliberately annoys others; blames others for his or her mistakes; spiteful or vindictive at least twice during past 6mo
• tx: children <12, effective parenting, positive attention with praise and reinforcement of desirable behavior, ignore inappropriate behavior, give clear, brief commands, reduce task complexity, eliminate competing influences, family tx if >18
• prognosis: 25% will develop conduct disorder

Question 7

autism spectrum disorders

Answer 7

• 1% gen pop
• RF: advanced parental age, low birth weight, fetal exposure to Valproate, 15% have known genetic mutation, M 4x >F, AA, associated with anxiety, depression, mental retardation
• sxs: typically observed during second year of life, but may be seen <12mo
  
  • persistent deficits in social communication and interaction (deficits in social-emotional reciprocity, deficits in nonverbal communicative behaviors, deficits in developing, maintaining, and understanding relationships (i.e. sharing imaginative play, etc.)
  • restricted, repetetive patterns of behavior, interests, activities
    
    • 2 of the following: stereotyped or repetetie motor mvmts, insistence on sameness, fixated interests that are abnl in intensity or focus, hyper or hyporeactivity to sensory input
• signs: motor deficits (odd gait, clumsiness, abnl motor signs), self-injury (head banging, biting the wrist), disruptive or challenging behaviors
• complications: seizures
• tx: edu and behavioral intervention, focus on speech and language tx, communication skills and vocab
  
  • meds: abilify, risperdal, SSRIs
  • psychotx
  • good prognosis if fnal language by age 5, poor prognosis if epilepsy as comorbidity