Externalising Disorders: ADHD, ODD, CD

Question 1

Disruptive Behavior Disorders

Answer 1

Disorders characterised by problems in behavior, rather than emotions
Attention Deficit Hyperactivity Disorder (ADHD)
• Distractible, impulsive
Oppositional Defiant Disorder (ODD)
• Stubborn, hostile, defiant
Conduct Disorder (CD)
Aggressive and antisocial
DSM-5: ADHD comes under “neurodevelopmental disorders” and ODD &CD come under “disruptive disorders”.

Question 2

ADHD

Answer 2

More common in boys.
Still active research and controversy on
What is the core problem?
What are the subtypes?
Gender differences (girls more inattentive)
Less (professional) controversy on causes and treatments
Stimulant medication is the best studied
medication in child psychiatry, and the most effective
But, it is not necessarily enough…

Question 3

ADHD: DSM-5 diagnostic criteria

Answer 3

Six* or more of these attentional symptoms for 6+ months, inconsistent with developmental level, negative impact, not just oppositional or not understanding;
 Often fails to attend to details, careless mistakes
 Often has difficulty sustaining attention
 Often does not listen
 Often does not follow through and finish tasks
 Often has difficulty organizing tasks
 Often avoids or dislikes tasks that require sustained
mental effort
 Often loses things
 Often easily distracted
 Often forgetful
*(age 17 + only need 5 symptoms)

And/or, six or more of these hyperactivity/impulsivity sx
for 6+ months, inconsistent with developmental level, negative impact, not just oppositional or not understanding;
 Often fidgets or squirms
 Often leaves seat inappropriately
 Often runs around or climbs inappropriately (restless in
adolescence/adults)
 Often has difficulty playing or engaging in leisure activities quietly
 Often seems “on the go” or “driven by a motor”
 Often talks incessantly
 Often blurts out answers before question are completed
 Often has difficulty waiting turn
 Often interrupts or intrudes

Some symptoms and impairment started by age twelve
Impairment in two or more settings
Clear evidence symptoms interfere with or reduce quality of social, academic or occupational functioning
Differentials: Not schizophrenia, other psychosis, or better explained by another disorder
Subtypes
• Combined presentation (both sets of criteria met)
• Predominantly inattentive presentation
• Predominantly hyperactive/impulsive presentation

Question 4

Types of ADHD

Answer 4

Combined type is most common in mental health settings
Inattentive type looks different
 Spacey, quiet, slow thinking
 Fewer behavior problems
 Some think this is a separate disorder

Question 5

When is ADHD diagnosed?

Answer 5

Usually first diagnosed early in primary school
If milder, especially inattentive type, may not be diagnosed until adolescence or adulthood
Symptoms continue in adolescence and adulthood, but shift away from behavior problems e.g., substance abuse/overspending etc.
This is more specifically described in DSM5 (please read)

Question 6

Aetiology of ADHD

Answer 6

Theories about sugar, allergies, yeast, fluorescent lighting, motion sickness, bad parenting, urban living, too much TV- have not been consistently supported
 Still a lot of active research and speculation about what does cause it
Strongest evidence for genetic and neurobiological factors.
High heritability.

Question 7

Aetiology of ADHD-HI (hyperactivity) type (Barkley Theory)

Answer 7

 Biological and environmental risk factors work together to shape symptoms

Factors such as
 Genetic risk
 Prenatal exposure to alcohol, tobacco, stress
 Pregnancy complications
Lead to
 Disturbances in dopamine transmission
 Abnormalities in frontal lobes and basal ganglia
 Neurological differences lead to a range of difficulties (lack of inhibition).

This produces
 Failure to inhibit inappropriate responses, which leads to
• Deficits in working memory and self-regulation
• Behavioral symptoms: inattention, impulsivity, hyperactivity
• Impaired social and academic development
• Disruptions in parenting
• Oppositional and conduct disordered symptoms

Question 8

Factors Associated with ADHD

Answer 8

 Psychological/social components
 ADHD affects
• Learning emotional control
• Peer relationships
• Family relationships
• Self-esteem
 ADHD is affected by
• Structure/Boundaries
• Stress

Question 9

NHMRC Guidelines on the Assessment & Management of ADHD Diagnosis in Children & Adolescents (2012)

Answer 9

 Thorough assessment of ADHD requires specialist assessment & should include:
 A comprehensive medical, developmental and mental health assessment of the child
 A cultural and social assessment (meaning of behaviours)
 Determine whether symptoms are devt. excessive for the child’s age
 Consider any comorbid diagnosis

If indicated additional assessment may be required including:
 A cognitive and behavioural assessment
 Allied health and educational assessment
 The assistance of an interpreter.

Question 10

NHMRC Clinical Practice Guidelines-Diagnosis

Answer 10

 DSM or ICD criteria must be used
 Symptoms must be deemed by a specialist clinician and be maladaptive and excessive for the child’s developmental level; persisted over time (at least 6 months); be evident in more than one setting; have caused significant functional impairment; and not explained by any other condition.

 Should include physical exam and a holistic assessment of child and family circumstances
 Diagnosis of young children (under 7) should be made by a specialist clinician who observes the child over several months and reviews them as they start school.

Question 11

Assessment of ADHD

Answer 11

Rating scales e.g., BASC, BRIEF (across home
and school)
Connors-multiple versions should be used (gold
standard)
Cog assessment where indicated (e.g., WMI on
WISCV)
Academic Ax (e.g.WIAT)
Other assessments for attention e.g., TEACH likely
to be useful where possible.
Multidisciplinary AX e.g., speech path if indicated
In addition to clinical interview, undertake a developmental Hx, family Hx and mental state
assessment of the child and their system(as per lecture 1).

Question 12

NHMRC Clinical Practice Guidelines -Management adhd

Answer 12

 Treatment plan should consider:
• Holistic needs of child/family
• Prioritisation of interventions to fit target symptoms (guided by assessment)
• Regular monitoring and evaluation of efficacy/treatment review
• Psychoeducation and treatment information for parents (ideally written, if appropriate)
• Treatment of comorbid conditions
• Family resources
Treatment should include a range of clinicians and service providers including teachers and parents as active partners. Treatment should include psychological, pharmacological &/or educational interventions used alone or in combination

Where indicated young children and school age children diagnosed with ADHD may benefit from psychological interventions that have an evidence base to address externalising and internalising symptoms.
Consideration should be given to the ability of
the child/family to implement strategies
Consider CBT for adolescents with internalising symptoms
Monitor effectiveness and consider relapse prevention booster sessions if indicated.

Question 13

Best Practice Guidelines -Treatment adhd

Answer 13

 Parent training programmes may be helpful for many families:
• Can be individualised or group approach
• E.g. TRIPLE P; The Incredible Years etc.
• Often useful for any parent dealing with challenging behaviours to learn about behavioural principles and positive parenting approaches
For young children psychological and family interventions should be trialled first prior to medication

Question 14

APS Evidence Based Review of Psychological

Treatments: ADHD

Answer 14

What psychological treatments work?
 Level 1 evidence for Behaviour Therapy (6-18 years) and Family Interventions (3-15 years).
 Level II evidence for play based therapy (5-11 years) and psychoeducation (3-20 years).

Question 15

Background: Effective parenting adhd

Answer 15

 Research has found effective parents respond successfully to demands:

1. Impose limits on unacceptable behaviour (consequences/consistency etc)
2. Maintain an emotionally positive parent child relationship (Kochanska & Aksan, 1995) i.e., involved, attuned, regulated.

Question 16

Assessment and formulation is important.

Don’t rush the process. adhd

Answer 16

 What behaviours are of concern? To whom?
 Specification of behaviour. Need a precise description.
Measurement of behaviour across relevant settings/informants:
 Frequency, duration, outcomes, time (when?), context
(where), intensity etc. Behavioural excess or deficit?
 Assessment of the function of the behaviour (use interview, recording sheets, checklists, direct observation)
A baseline needs to be established (see handouts) and then ongoing monitoring over time to determine if strategies effective

Question 17

Setting up for successful Behavioural

Interventions adhd

Answer 17

Monitoring.
Record a baseline e.g., if observing a child in the classroom record behaviours that can be observed directly e.g., talking, hitting
Examine antecedents and consequences Identify maintaining stimuli See Handouts (e.g., ABC chart)

Question 18

Contingency Management Concepts to

manage behaviours

Answer 18

Punishment-contingent aversive stimuli eg washing
floors
Response cost –contingent removal of a reinforcer
following problem behaviour (removal of screen time)
Time out-withdrawal from all reinforcement
Extinction-elimination of contingent reinforcers (ignoring misbehaviour)
Shaping-reinforcing of successive approximations
(e.g tokens/start charts)
Positive focus to strategies is important.
See class handouts and resources on canvas for
suggested strategies e.g., time-out.

Question 19

Basic principles of behavioural

interventions

Answer 19

 Desirable behaviours need to be followed by reinforcements (eg rewards/praise).
 Reinforcement can be positive (contingent presentation of a pleasant stimulus) or negative (removal of an unpleasant stimulus ).
 But important to make consequences non punitive/non aversive if developing a program!

Question 20

Teaching and maintaining new behaviours

Answer 20

 Better to start with a continuous schedule of reinforcement.
 Importance of consistency across settings/carers etc.
 Once behaviour is established it’s better to move to variable (unpredictable) or intermittent reinforcement (eg fixed ratio)
 Consider the timing of starting a program and resources (eg staffing).

Question 21

Natural and Logical Consequences and Rewards

Answer 21

 Consequences should be logical, clear, short, immediate and age appropriate.
 For instance a 2 year old child that throws a toy truck
has the toy removed till after nap time.
 Rewards:
Use tokens, star charts, special badges, stickers etc
 Reward categories:
Excursions, food, sports, social, play, toys, helping etc.

Question 22

Helping parents to address behavioural issues early strategies to implement early

Answer 22

 Playing together
 Praising (verbal and non verbal)
 Reasonable expectations
 Join in make believe play
 Attend and be mindful
 Reflect and describe what you see happening (e.g., I can see you are putting your block on top of the tower)
 Have fun
 Use positive language
 Modelling (e.g mummy is waiting her turn before she throws the dice)
 Notice the good. Ignore the bad
 When ignoring (e.g., during a tantrum), avoid eye contact and discussion

Question 23

Oppositional Defiant Disorder (DSM5)

Answer 23

Pattern of angry/irritable mood, argumentative behaviour or vindictiveness lasting at least six months, during which 4 SX and exhibited with at least one person (not a sibling):
Angry/irritable mood
• Often loses temper/touchy or easily annoyed/angry or
resentful
Argumentative/Defiant Behaviour
• Often argues with authority figures, children or adults/actively defies or refuses to comply with requests
or rules/ deliberately annoys others/blames others for
mistakes or misbehaviour
Vindictiveness
• Often spiteful or vindictive at least twice within the past 6 months

For children under 5 the behaviours should occur on most days for a 6 months period.
 For over 5 year olds, the behaviour should occur at least weekly for 6 months.
 Consider whether frequency of behaviours are normal for the child’s development and culture etc.
 Differential: can’t be given with disruptive mood dysregulation disorder (which is even more irritable and explosive)
 Need to specify severity (if mild/mod/severe)

Question 24

Associated Problems ODD

Answer 24

Learning disabilities/problems
ADHD
Substance abuse
Peer rejection
Depression and anxiety
Family dysfunction
Risky behaviours

Question 25

Aetiology ODD

Answer 25

 Temperament e.g., emotional regulation/reactive
 Attachment experiences
 Family stress/distress
 Parenting patterns
Critical, angry, threatening
Ineffective, multiple commands
Poor monitoring
Less parental involvement
Low on positive support
Attention for noncompliance

Question 26

Treatment ODD

Answer 26

 Especially for preschool, behavioural parent training programs
May be individual, group, self-directed
Some programs include the child directly, some do not.
Examples with an evidence base-Triple P, and Incredible Years
Generally effective, for those who participate
• But, at least 1/3 do not
• The families most at risk of ODD are stressed, troubled, disadvantaged families

 Establish priorities.
 Safety first-risk to life and well being (eg manage the child’s absconding/fire lighting etc )
 Try to tackle the most amenable issue to change first if dealing with multiple issues-give the family a sense of success!
 Build on the clients strengths and the systems resources.

Question 27

Goal setting for externalising problems

Answer 27

Work collaboratively with all parties-child/parent/school for consistency
 Goals should be observable and achievable (SMART Goals)
 Indicate in behavioural specific terms which behaviours the child will be doing differently e.g., To increase pro-social behaviour.
 Try to word positively. e.g To increase problem solving skills.

Question 28

Questions to help set priorities ODD

Answer 28

 What problem does the client (parent) see as most concerning?
 Which problem has the greatest impact on the child’s
functioning?
 Which problem is most easily solved?
 Consider using the miracle question.

Question 29

Get the parents on board… ODD

Answer 29

 Psycho-education.
 Provide information about the disorder.
 Reduces stress and increases compliance
 Consider linking parent with websites and self help books that are relevant to their child’s condition (e.g., Raising children’s network).
 Consider support groups/services for parents

Question 30

Parent Training Programmes ODD

Answer 30

 Most teach similar principles
Building positive interaction (attending)
Effective commands and compliance
Positive reinforcement
Effective use of time out
Monitoring and reinforcing behaviours
Appropriate expectations
See Barkley Parent Handouts

Question 31

Social Skills Training

Answer 31

 Goals: may include an increase in pro-social behaviour, problem solving and emotion regulation.
Example of a social skills group program may include:
 Greetings, conversation rules
 Understanding own feelings
 Understanding others feelings
 Managing angry feelings
 Joining in
 Giving compliments
 Playing fair

Question 32

References-Parenting Programs

Answer 32

The Incredible Years
 http://www.incredibleyears.com/programs/
Triple P
 https://www.triplep-parenting.net.au/au-uken/triplep/?
cdsid=q3n5s0enqv84nf0ial70ld2md6
 Tuning into Kids
http://www.tuningintokids.org.au/

parent works monash?

Question 33

Conduct Disorder and Oppositional Defiant

Disorder

Answer 33

 Both commonly seen in child MH clinics
 Both involve conflict with authority figures
 ODD typically starts younger
 Almost all CD could meet criteria for ODD
 ODD has more affective symptoms (eg anger)
 CD involves aggression towards others/animals and theft which ODD doesnt
 Younger onset of CD has worse prognosis (at least one symptom by 10 years)
 BUT, most kids with ODD don’t end up with CD

Question 34

Conduct Disorder

Answer 34

A Repetitive and persistent pattern of behavior in which the basic rights of others or major social norms or rules are violated; at least 3 of these 15…
Aggressive behaviors:
• Bullies, threatens, or intimidates
• Often initiates physical fights
• Has used a weapon that could cause serious harm
• Physically cruel to people
• Physically cruel to animals
• Stolen while confronting the victim
• Forced someone into sexual activity

Destructive behavior:
• Deliberate fire-setting
• Deliberate destruction of property
•Dishonesty:
• Broken into house, building or car
• Often lies to obtain goods, favors, or to avoid obligations
• Stealing without confronting victim (e.g., shoplifting)
•Rule-breaking:
• Often stays out at night despite parental rules, beginning before 13
• Run away from home overnight at least twice (or longer, once)
• Often truant from school, beginning before 13

Question 35

Typologies of CD

Answer 35

 Childhood/adolescent onset (one symptom by 10)
• Strong prognostic indicator
 Destructive/nondestructive
 Aggressive/non-aggressive
 Socialised/undersocialised
 Proactive/reactive aggression
 Callous-unemotional vs not…

Question 36

Risk Factors CD

Answer 36

Exposure to violence
Family discord/disturbance
Parenting patterns—harsh discipline, lack of supervision, lack of emotional support
Interpersonal problem-solving deficits
Peer problems—rejection or influence
Learning disabilities/cognitive deficits
Hostile attributional style
Genetics and temperament

Question 37

Associated Problems CD

Answer 37

Learning disabilities/problems
ADHD
Substance abuse
Peer rejection
Depression and anxiety
Family dysfunction
Risky behaviors
Chaotic backgrounds

Child onset worse outcomes than adolescent onset (mis-spent youth the only real issue). Child onset, likely more long term.

Question 38

Gender and CD

Answer 38

Most of this research is about boys
Rates are higher for boys
Rates of comorbid/risk factors are higher for boys
But does that mean girls don’t have CD?
•One US sample: 5.8% girls, 7.0% boys
•Most studies—2-4X boys > girls
• Why?

Question 39

What is best practice for the psych treatment

of CD?

Answer 39

Family focused interventions that are multimodal, intensive, engage the system; therapist provides considerable support and containment.
 Individual treatment is less effective than family/systemic based approaches but if offered should focus on skills and strengths (e.g. building skills) rather than underlying causes. Ref. Fonagy et al (2015).