ADHD, Disruptive, Impulse control and neurodevelopment Disorders

Psychiatric Evaluation of a Child

-Children differ from adults, crying and give accurate details about their emotional states

- You also get reliable information from:

1. Parents or caregivers: more reliable for information on child's

2. Teachers:

3. Child welfare/ juvenile justice system

What information do you get from parent and teachers

1. Parents or caregivers: more reliable for information on child's conduct, school performance, problems with the law

2. Teachers: Information on conduct, academic ability, social relations with peers

What does a child Drawing, playing, telling stories assess?

- Assess conceptualization and child's internal states

-Tests of cognitive and adaptive functioning

Attention Deficit Hyperactive Disorder (ADHD)

-Most common neuropsychiatric disorder

-Affects >10% of children and adolescents

-Can result in the development of comorbid conditions including anxiety, depression, and substance abuse

Epidemiology of ADHD

-Affects males and females

-Males more likely to be diagnosed due to hyperactivity

-Females likely to experience inattention and diagnosed with a learning disorder and ADHD in adulthood can result in comorbid anxiety and depression

Pathology of ADHD

Genetic and neurobiologic etiology

- Significantly smaller right prefrontal cortex, caudate nucleus, and globus

pallidus

(areas that are related to attention, stimulus processing, and impulsivity)

Neurotransmitters in ADHD

- Dopamine and norepinephrine,

- Decreased neurotransmission

-Serotonin is also affected

Effects of Dopamine in ADHD

- Normal effect: modulation of risk-taking behaviors, impulsivity, overall mood

-Possible genetic mutation of the receptor

- Decreased dopamine leads to inattention, impulsivity, hyperactivity

Effects of NE in ADHD

-Normal effect: focus, concentration, mood

-Decreased norepinephrine lead to poor concentration, inattention

Effects of Serotonin in ADHD

- Decreased serotonin causes hyperactivity, impulsivity, anxiety

-Increased causes a calming effectt

What CNS stimulants affect Dopamine, NE, Serotonin

-Amphetamine and methylphenidate

-Directly and indirectly affect these neurotransmitters

Environmental effects in ADHD

- Exposure to heavy metals

- Pesticides

- Premature birth, low birth weight

- Fetal exposure medication such as acetaminophen

- Brain injury

Comorbid conditions in ADHD

-Depression

- Anxiety

- Conduct disorder

- Oppositional defiant disorder

- Insomnia

- Addiction

- Tourette syndrome

- Autism

* Do they lead to ADHD or does ADHD causes them? We don't know

Clinical Presentation of ADHD

- Inattention and/or hyperactivity/impulsivity

- Look Age, gender, culture, religion

- Severity depends on circumstances

ADHD in males vs females

- Males: have higher rates of the hyperactive

- Females: higher rates of inattentive subtype

Hyperactive sx of ADHD

- Excessive fidgeting

- Restlessness

- Frequent postural changes

- Excessive talking

- Loudness

- Inappropriate running/climbing

- Pressured and/or rapid speech

- Interruptive communication

** Common in childhood,

Inattention in ADHD

- Frequent distraction

- Losing items

- Missing appointments/deadlines, failing to turn in assignments

- Avoiding tasks that require sustained mental effort

- Poor organizational skills

** Unnoticed at a young age and become more apparent in adulthood

T/F you can have Impaired function in one setting and be diagnose with ADHD

FALSE

-Must have Impaired function in multiple settings to diagnose ADHD

-Must occur in school (Academic)l, home/work (occupational), and social situations

Third party observed in the dx of ADHD

-Interviewed with a written assessment (Vanderbilt Assessment)

- In younger children this should be completed by guardian and teacher, subjective,

- Self-reporting

assessments for teenagers and adults.

- This is not a diagnostic test

** There is no diagnostic test for ADHD

* You also do a physical examination

First sings of ADHD

-Hyperactivity and impulsivity

- Seen as early as age 3 and up

-Peak age 7-9, and then decline

** inattentive type are dx at a later age bc it can be said at earlier ages that their behavior is normal

Comorbid disorders that have similar symptoms as ADHD

-Bipolar disorder

- Dyslexia

- Autism

- Substance abuse

- Conduct disorder

Diagnostic studies to r/o other conditions other than ADHD

- Brain imaging

- Blood work

-EEG

- EKG to evaluate cardiac risk factors ( bc ADHD is Treated with stimulants not the be given in CVD)

T/F you must do written assessment and quantitative test should be document before dx

TRUE

-To check if its nothing else

-If symptoms occur with psychotic disorders like schizophrenia, personality disorders, or in

substance abuse, other diagnoses should be consider don't dx ADHD

Dx of ADHD (specifiers)

- inattentive

- hyperactive/impulsive

- combined.

-Severity is mild, moderate, or severe.

ADHD rating scales/questionnaires

-Vanderbilt Assessment Scale: child >4y

-Conners Comprehensive Behavior Rating Scales: only scale for preschool-aged children

Test of Variable attention (TOVA)

- Support diagnosis.

- Respond to a target stimuli:

- In ADHD you see:

Decreased attention: error of omission (give a pattern to remember but they forget it and don't press the bottom)

Impulsivity: errors of commission (press bottom before they even see the pattern)

ADHD stimulant medication

-Except for preschool-aged children first-line

- Benefits usually outweigh risks

- Includes: Amphetamines or methylphenidate

- It improve executive functioning and decrease impulsivity

MOA of ADHD stimulants

- Block the reuptake of dopamine and norepinephrine into the terminal by blocking the dopamine transporter and norepinephrine transporter; increases the amount of dopamine and norepinephrine in the synaptic cleft

Why no stimulant in Children

- bc you want to make sure its not part of their normal Development

- For children first line should be behavior Therapy, reward system

*** EVERYONE SHOULD BE OFFERED BEHAVIORAL THERAPY NOT JUST CHILDREN

Type of stimulants

- Amphetamine derivative (AMP): Amphetamine sals and dextroamphetamine (d-AMP)

- Methylphenidates :Metyphenidates and dexmethylphenidate (d-MPH)

**All target executive function

Methylphenidate vs. Amphetamines in children in adults

- Methylphenidate rather than amphetamines or nonstimulant medication for pre-school

child

- Amphetamine over methylphenidate for adults

Short acting stimulants in ADHD

- Short acting formulations: Initial treatment in children <6 years

- More likely to be abused and diverted meaning given to others

Types of short active stimulants

● Amphetamines: Adderall, Dextrostat, Procentra

● Methylphenidate: Ritalin, focalin

Long acting stimulants

- No doses small enough for young children

- If >6y longer-acting preparations may be used initially, start low titrate up.

- Duration of action: >4h

Type of long acting stimulants

● Amphetamine: Dexedrine, Adderall XR, Vyvanse

● Methylphenidate: Concerta, Focalin, Daytrana (patch)

T/F Combination of a long-acting and late-afternoon short-acting medication is never used

FALSE

Yes this is used to tx ADHD

S/e of stimulant medication

- Dry mouth

- Insomnia (when its long acting)

- Irritability

- Anxiety

- Diminished appetite

- Weight loss

- Headaches

- Cardiovascular effects,

- Subject to misuse, abuse, dependence,

- Increased tic disorders

- Psychosis

- Decelerated growth

Contraindications with stimulants

- History of chest pain

- Palpitations

- Syncope

- Myocardial infarction

- Arrhythmia

Non Stimulant ADHD medication

- Atomoxetine

- Viloxazine

- Anti depressant

- Alpha 2 adrenergic agonists

Atomoxetine (Strattera)

MOA: norepinephrine re-uptake inhibitor

- Minimal abuse potential

- Used in adults

- Can take up to 4 weeks for therapeutic levels

Preferred in childbearing age, history of

addiction or substance use disorder, heart disease, or seizure disorders.

Atomoxetine s/e

- Dry mouth

- Insomnia

- Nausea

- Decreased appetite

- Constipation

- Decreased libido

- Urinary hesitancy

- Dizziness, and sweating

- Aggressive behavior

- Psychosis, mania

Viloxazine (Qelbree)

-selectively inhibits of norepinephrine and serotonin reuptake

-Can take up to 4 weeks for therapeutic levels

-Side effects: insomnia, fatigue, irritability, nausea, headache, elevation of blood pressure or heart rate, activation of mania or hypomania, and possible emergence of suicidal thoughts

Antidepressants

- Bupropion (atypical)

-Notriptyline (TCA)

Bupropion (Wellbutrin) and s/e

- Preferred if history of major depression and ADHD

-Side effects: dry mouth, nausea, insomnia, dizziness, anxiety, dyspepsia, sinusitis, and tremor, increased risk of seizures

Notriptyline (Pamelor) and s/e

-Preferred if comorbid depression or anxiety

- Not frequently abused, single dailydosing

- Less effective and poorly tolerated

- Cardiotoxic

-Side effects: anticholinergic and cardiotoxic (lethal overdose), cardiovascular effects: hypotension, hypertension, tachycardia, QTc prolongation

Alpha 2 adrenergic agonists

-Clonidine, Guanfacine

-Considered third line

- Used for impulsivity and hyperactivity

- Monotherapy or adjunct to stimulants

-Adverse effects: sedation, hypotension, dry mouth

Behavioral Therapy

- reward/consequence system

- Goal is positive reinforcement for desired behaviors, consistent responses to undesirable behavior

- Psychotherapy for comorbid anxiety, depression, mood lability

- Collaboration with schools to facilitate accommodations: extended exam time, private tutoring, decreased sensory environments, reward systems

Intermittent Explosive Disorder (IED)

- Recurrent behavioral outbursts, failure to control aggressive impulses to things that shouldn't cause this behavior

- Includes: road rage, domestic violence, child abuse, and property damage. Public and private outbursts, particularly those that cause injury or property damage may result in arrest

Intermittent explosive disorder criteria

- In pt older than 6

- Verbal aggression /physical aggression without destruction or injury: 2 or more weekly in 3 months

- Outbursts with destruction or injury: 3 in 12 months

Intermittent explosive disorder Coexist with?

- Depression

- Substance use,

- PTSD

- Personality disorders

What is intermittent explosive disorder Treated with

- Treated antidepressants and mood stabilizers

Kleptomania

- Impulse control disorder characterized by the inability to resist the impulse to steal

- Often objects that are stolen are not needed, and often have no significant monitory value

- Tension leading up to the theft, followed by feelings of gratification or relief after

-Stealing not triggered by hallucinations or anger

What neurotransmitters are related to kleptomania

- Related to serotonin, dopamine, and behavioral addiction

Management of kleptomania

-Lithium, anti-epileptics

- Opioid antagonists

- Antidepressants

- Psychotherapy

What coexist with Kleptomania

- Mood disorder

- Anxiety

- Substance abuse,

- Eating disorder

- Other impulse disorders

Pyromania

- Strong urge to watch existing fires, or to set new fires so engage in arson

- Fascination with and attraction to fire and fire-starting paraphernalia

- Deliberate and repeated

setting of fires

- Tension prior followed by feelings of pleasure, gratification, or relief during or after fire-starting

Management of pyromania

- SSRIs

- Opiate antagonists

- Mood stabilizers

- Behavior therapy

Trichotillomania

- Recurrent pulling out of own hair, feel compelled to pull hairs which can result in hair loss

Medications used for trichotillomania

- Antidepressants

- Medication for obsessive-compulsive symptoms

- SSRIs

- Mood stabilizers

Conduct disorder

- Older than 12 yrs old

- LEGAL TROUBLE

- Related to conduct

- Issues with impulse control, and disruptive behavior.

- Violate norms in society, violate age-appropriate norms

- Hx of behavior that violates others and societal norms with a negative impact on academic,social, and occupational functioning

- Can progress to severe and criminal behavior and diagnosis of antisocial personality disorder

Risks factors for conduct disorder

- Neurocognitive deficits

- Neurochemical irregularities

- Autonomic irregularities

- Environmental (exposure to toxins, poor quality early childcare)

- Relationship issue

- Low serotonin

- Negative peer pressure

- Exposed to violence

Clinical Manifestations of conduct disorder

1. Aggression to humans and animals

2. Lying or stealing

3. Property destruction

4. Serious violation of rules

5. No concern over performance

6. Lack of guilt

7. Lack of empathy

8. Lack of emotion

9. Superficial emotion with others

How to dx conduct disorder

- Vanderbilt Assessment Scale

- Strengths and Difficulties Questionnaire

** Getting information from parents or caregivers and teachers

Conduct disorder management

- Psychosocial interventions are considered first-line

- Individual: anger management, problem-solving skills, and development of social skills.

- Family: teaching consistent parenting, modeling empathy and emotional expression

Stimulant medication in conduct disorder

- Effective in controlling the specific symptoms of inattention, impulsivity, and

hyperactivity

- However, used alone does not always improve parent-child, teacher-child, or peer relationships

Antipsychotics used in conduct disorder

- Risperidone (extrapyramidal symptoms), - Lithium for aggression

- SSRI for impulsivity and mood swings

- Clonidine

Prognosis conduct disorder

- Increased risk of substance abuse and antisocial personality disorder

Oppositional Defiant Disorder

- NO LEGAL TROUBLE

-AUTHORITY TOUBLE

-Recurrent pattern of angry/irritable mood, argumentative/defiant behavior, disobedience towards authority figures

- Lasting at least 6 months

- Pathological -extension of normal development

- Children rebel against authority for autonomy; not deliberate aggression, no serious rule violation, normal intelligence, poor performance in school

Risk for oppositional defiant disorder

- Harsh, punitive, or inconsistent parenting

- Parents reinforce disruptive and deviant

behaviors with negative attention

- History of ADH

- Neglectful parenting

- Highly authoritarian parenting

- Negative behaviors rewarded with negative attention so increases undesired behavior

Etiology of oppositional defiant disorder

- MC in Boys before puberty

- Equally common in boys and girls

- Dx at 8 or older

- No dx before age 3

Symptoms of Oppositional Defiant Disorder

Symptoms:

1. Angry/Irritable Mood: Loses temper easy angry and resentful

2. Argumentative/Defiant Behavior

Argue with authority figures or adults

Refuse to comply with requests from authority figures

3. Deliberately annoys others and blames others for his or her mistakes or poor

behavior

4. Vindictiveness or spiteful

Management of oppositional defiant disorder

- Assess for ADHD and learning disorders

- Psychotherapy, group therapy to developlistening, empathy and effective problem solving skills

Oppositional defiant disorder coexist with

- Associated with substance abuse

- Mood disorders,

- ADHD

- Can progress to conduct disorder

Intellectual Disability

● Impairments in three domains:

1. Cognitive: reading, writing, math, and language

2. Social: empathy, social judgment, interpersonal communication skills

3. Self management: personal care, job responsibilities, money management, recreation, organizing school/work tasks

Sings of intellectual disorder

- Language delay: FIRST SIGN : No 2 word phrase by age 2 and no babbling at 12 months

- Delays in self-feeding, toileting, and dressing, drooling

Comorbid conditions with intellectual disability

- Depression

- ADHD,

- ASD.

Epidemiology of intellectual disability

- 1% of population

- Mild intellectual disability often unrecognized

- Males twice as frequent as females

Etiology of Intellectual Disability

1. Genetic: chromosome mutations, inherited conditions

2. Developmental errors:

- PKU: Phenylketonuria: Inborn error of metabolism. Cannot convert enzymes.

- Rett's disorder

3. Prenatal infection and toxin exposure- TORCH

TORCH

T- toxoplasmosis

O- other (syphilis, AIDS, alcohol, drugs)

R- Rubella,

C- cytomegalovirus

H- Herpes simplex

T/F Rett's disorder only occurs in males

FALSE

ONLY IN FEMALES

Dx of Intellectual Disability

- Clinical assessment and standardized testing of intelligence, severity based on adaptive functioning rather than IQ scores

- IQ tests: measures deficits in intellectual functioning

- ID is 2 standard deviations or more below the population.

- IQ<70

- Persistence of infantile behavior: low frustration intolerance, hyperactivity, aggression, self-injurious behavior, mood instability

Impairment in ADLs in intellectual disability

- In childhood or adolescence.

1. Communication

2. Social skills

3. Independence: home/school: Ex/ laundry, cleaning, cooking, shopping

4. Academic/ occupational

Management of intellectual disability

- Special education and training to reach potentia

- Early intervention for children less than 3

- special education services for children 3-21

- Support services for families

Coexisting disorders with intellectual disability

- Oppositional defiant disorder

- Heart defect

- Seizure disorders

Complications of intellectual disorder

- Social isolation

- Self care

- Prognosis depends on underlying disorders

Learning disorder DSM- V criteria

- Deficit in academic achievement and learning

- Difficulty with academic skills: reading, math, written expression

Epidemiology

- 5-17% of children

What do r/o in learning disorder

- Rule out issues such as sensory deficits, poor teaching, cultural factors, dyslexia

- Rule out issues such as sensory deficits, poor teaching, cultural factors, dyslexia

Management of learning disorder

- Remedial learning

What are the pre requisites for psychopath (anti social disorder)

- Oppositional disorder leads to Conductive disorder

- Conductive disorder leads to psychopath

Autism Spectrum Disorder

- Degree of difficulty in social interaction, verbal/non-verbal communication, and repetitive behaviors

- Continuum: Mild to severe

What disability and difficulties are associated with autism spectrum disorder

- Intellectual disability

- Difficulties in motor coordination

- Difficulty in attention

*some excel in music, math, science

Types of autism disorder merged in the DSM-5 Vs DMS-4

- Merges all autism disorders into Autism spectrum disorder

1. Previously were autistic disorder

2. Childhood disintegrative disorder

3. Pervasive developmental disorder

4. Asperger syndrome

Behaviors in autism spectrum disorder

- All have communication deficits: respond inappropriately, misreading nonverbal interactions

-Need routines, sensitive to changes in environment

- focused on inappropriate items

- Symptoms begin in early childhood

** Early intervention and behavioral therapy can improve outcomes

Epidemiology and etiology of autism spectrum disorder

-1 in 68

- Influence on early brain development: genetics,

- Environmental factors

Risk factors of autism spectrum disorder

- Advanced parental age at conception

- Perinatal complications: congenital rubella, PKU, complications in pregnancy and delivery, poor prenatal care

** 40% have average to above average intellectual abilities, some are disabled and cannot live independently

Autism spectrum disorder classes of sx

1. Social interactions

2. Communication challenges

3. Repetitive behavior

Social interactions

- Social isolation

- Delayed babbling

- Appear disconnected.

- Deficits in verbal-nonverbal communication

- Difficulty with understating body languages and expression

- Outbursts in inappropriate situations, disruptive, aggressive behavior.

- Easily lose control in overwhelming, frustrating situations (social anxiety) leading to self inflicted injury

Communications challenges

- Language delay

- Monologues on favorite subject giving others little chance to comment.

- Tone of voice does not match their feeling

- Frustration

- Inappropriate behavior

Repetitive behaviors

- Hand flapping, rocking, jumping, twirling, arranging and rearranging objects, repeating words and phrases.

- Might spend hours lining up toys instead of pretend play

- Restricted interests: Preoccupations or obsessions (numbers, dates, symbols, scienceOCD, resist change)