1.5 ADHD, ODD, CD (S).pdf

OT1026 MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS SHIFT 1 Attention-Deficit Hyperactivity Disorder, LESSON Oppositional Defiant Disorder...

OT1026 MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS SHIFT 1 Attention-Deficit Hyperactivity Disorder, LESSON Oppositional Defiant Disorder, Conduct Disorder Dra. Richelle Santiano | 09/13/24 05 observation that stimulant medications increased TABLE OF CONTENTS A. Attention Deficit Hyperactivity Disorder # sustained attention and improved focus A.1. History Persistent pattern of inattention and/or hyperactivity- A.2. Prevalence impulsivity that interferes with functioning or development A.3. Etiology # Inattention manifests behaviorally as wandering off task, A.4. Neurobiologic Basis and Genetics lacking persistence, having difficulty sustaining focus, and A.5. Risk Factors being disorganized and is not due to defiance or lack of A.6. Clinical Features comprehension A.7. Diagnostic Criteria A.8. Associated Features Supporting Hyperactivity refers to excessive motor activity (such as Diagnosis a child running about) when it is not appropriate, or A.9. Development and Course excessive fidgeting, tapping, or talkativeness A.10. Functional Consequences In adults, hyperactivity may manifest as extreme A.11. Differential Diagnoses restlessness or wearing others out with their activity. A.12. Comorbidity Impulsivity refers to hasty actions that occur in the A.13. Diagnosis and Lab Examination A.14. Pharmacologic Treatment moment without forethought and that have high potential A.15. Non-pharmacological Treatment for harm to the individual (e.g., darting into the street A.16. Prognosis without looking) B. Oppositional Defiant Disorder Impulsive behaviors may manifest as social intrusiveness B.1. Prevalence (e.g., interrupting others excessively) and/or as making B.2. Risk Factors important decisions without consideration of long-term B.3. Etiology consequences (e.g., taking a job without adequate B.4. Types B.5. Clinical Features information) B.5.1. Diagnostic Criteria B.5.2. Differential Diagnosis Inattention 15% B.5.3. Comorbidity Associated with anxiety and depression B.6. Course and Prognosis B.7. Treatment Hyperactivity-impulsivity 5% C. Conduct Disorder Associated with oppositional defiant disorder and C.1. Prevalence conduct disorder C.2. Risk Factors C.3. Neurobiological Factors Combined 80% C.4. Clinical Features C.5. Gender-related Diagnostic Issues C.6. Differential Diagnoses PREVALENCE C.7. Comorbid Factors Most common chronic behavioral disorder in children C.8. Course and Prognosis 3-5% of school-aged children worldwide C.9. Treatment 2.5% of adults Males > females LEGEND 2:1 in children and 1.6:1 in adults. ★ Important / Take Note ✤ Textbook Information The rate of ADHD in parents and siblings of children with ➤ Lecturer’s Verbatim ❐ Other Transes/Resources ADHD is 2-8 times greater than in the general population ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD) ETIOLOGY There is no single underlying cause of ADHD HISTORY It occurs both in the absence of any identifiable risk Early 1900s: “hyperactive syndrome” - impulsive, factors, and in association with other childhood conditions disinhibited, and hyperactive children even those with such as motor dyspraxia, tics, learning problems, speech neurological damage due to encephalitis and language disorders, sleep disorders, oppositional In 1960s: “minimal brain damage” - a heterogeneous behavior, enuresis, and encopresis group of children with poor coordination, learning Overactive and socially disruptive behavior is common in disabilities, and emotional lability, but without specific children who have evidence of injury from infections, neurological disorders head trauma, toxic exposures, and extreme prematurity Many hypotheses have been suggested to explain ADHD symptoms including theories of abnormal arousal and poor ability to modulate emotions - supported by the UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 1 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD NEUROBIOLOGIC BASIS AND GENETICS Families of ADHD/CD children are notable for the high incidence of sociopathy and alcoholism Parents of children with ADHD have elevated ratings of ADHD symptoms First- degree relatives are at a 4.6- to 7.6-fold risk of developing the disorder ADHD is highly heritable, probably based on multiple genes. Several linkage studies implicate a 7-repeat polymorphism of the dopamine receptor D4 (DRD4) gene, mapped to chromosome 11p 15.5, and also a polymorphism of a dopamine transporter (DAT1) The prefrontal cortex of the brain has been implicated because of its high utilization of dopamine and its reciprocal connections with other brain regions involved in attention, inhibition, decision-making, response inhibition, working memory, and vigilance Animal studies have shown that other brain regions such as locus coeruleus, which consists predominantly of noradrenergic neurons, also play a major role in attention Neuroanatomical areas involved in ADHD: superior and temporal cortices with focusing attention; external parietal and corpus striatal regions with motor executive CLINICAL FEATURES Signs begin before age 7 years and should persist for at functions; the hippocampus with encoding of memory least 6 months in two or more settings (e.g., home, traces; and the prefrontal cortex with shifting from one school, or play) stimulus to another Second year of life was found to be the earliest in which The right frontal lobe is reportedly smaller than normal in ADHD symptoms could be detected and age 3 to 5 years ADHD structural imaging, and the striatum has abnormal to be the peak time of onset morphology Primary manifestations: cognitive disorganization, The cerebellar, temporal gray matter, and total cerebral distractibility, inattention, impulsivity, and hyperactivity volume are smaller Secondary manifestations: disruptive behaviors, poor Corpus callosum size is reduced as well as the inferior social skills, emotional immaturity, fidgeting, poor cerebellar vermis, posterior lobe academic performance, and excessive talking Regional cerebral blood flow is diminished in striatum and Feeding difficulty and sleep disturbances in infancy and frontal lobes in ADHD the preschool period are commonly reported precursors Power spectrum analysis indicates prefrontal under- Young children with hyperactivity explore their activation and cerebral glucose metabolism is diminished environment with unusual persistence, which accounts for generally, but most notably, in the prefrontal cortex the increased frequency of accidental poisonings and traumatic brain injury in ADHD RISK FACTORS The hyperactivity becomes an occasion for disapproval Temperamental from teachers at times when school children are expected ○ ADHD is associated with reduced behavioral to sit still and pay attention. This disapproval may be inhibition, effortful control, or constraint; negative partly responsible for the high stealing and truancy rates emotionality; and/or elevated novelty seeking among hyperactive children Environmental Young children with ADHD initially show no signs of ○ Very low birth weight, smoking during distress, but negative reactions from adults and peers pregnancy, history of child abuse, maltreatment, gradually engender feelings of inadequacy, and this can neglect, multiple foster placements, neurotoxin lead to withdrawal or aggression exposure (lead), infections (encephalitis), or Hyperactive children are seen as quarrelsome, irritable, alcohol exposure in utero, exposure to defiant, untruthful, and destructive environmental toxicants The discipline imposed by the school and the need to Course modifiers repeat grades further contribute to learning failure and ○ Family interaction patterns in early childhood social maladjustment may influence its course or contribute to Non-hyperactive children with attention deficit are secondary development of conduct problems misperceived as undermotivated or lazy, and the diagnosis is often missed UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 2 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD ADHD is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by Diagnostic Criteria others as being restless or difficult to keep up with). f. Often talks excessively. A. A persistent pattern of inattention and/or hyperactivity-impulsivity g. Often blurts out an answer before a question has been that interferes with functioning or development, as characterized by completed (e.g., completes people's sentences; cannot (1) and/or (2): wait for turn in conversation). 1. Inattention: Six (or more) of the following symptoms have h. Often has difficulty waiting his or her turn (e.g., while persisted for at least 6 months to a degree that is inconsistent waiting in line). with developmental level and that negatively impacts directly i. Often interrupts or intrudes on others (e.g., butts into on social and academic/occupational activities: conversations, games, or activities; may start using other Note: The symptoms are not solely a manifestation of people's things without asking or receiving per-mission; oppositional behavior, defi-ance, hostility, or failure to for adolescents and adults, may intrude into or take over understand tasks or instructions. For older adolescents and what others are doing). adults (age 17 and older), at least five symptoms are required a. Often fails to give close attention to details or makes B. Several inattentive or hyperactive-impulsive symptoms were careless mistakes in schoolwork, at work, or during other present prior to age 12 years activities (e.g., overlooks or misses details, work is inaccurate). C. Several inattentive or hyperactive-impulsive symptoms are present b. Often has difficulty sustaining attention in tasks or play in two or more settings (e.g., at home, school, or work; with friends activities (e.g., has difficulty remaining focused during or relatives; in other activities) lectures, conversations, or lengthy reading) D. There is clear evidence that the symptoms interfere with, or reduce c. Often does not seem to listen when spoken to directly the quality of, so-cial, academic, or occupational functioning (e.g., mind seems elsewhere, even in the absence of any obvious distraction). E. The symptoms do not occur exclusively during the course of d. Often does not follow through on instructions and fails to schizophrenia or another psychotic disorder and are not better finish schoolwork, chores, or duties in the workplace explained by another mental disorder (e.g., mood disorder, anxiety (e.g., starts tasks but quickly loses focus and is easily disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal) sidetracked). e. Often has difficulty organizing tasks and activities (e.g., Specify whether: difficulty managing sequential tasks; difficulty keeping 314.01 (F90.2) Combined presentation: If both Criterion A1 materials and belongings in order; messy, disorganized (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for work; has poor time management; fails to meet the past 6 months. deadlines). 314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is f. Often avoids, dislikes, or is reluctant to engage in tasks not met for the past 6 months. that require sustained mental effort (e.g., schoolwork or 314.01 (F90.1) Predominantly hyperactive/impulsive homework; for older adolescents and adults, preparing presentation: If Criterion A2 (hy-peractivity-impulsivity) is met and reports, completing forms, reviewing lengthy papers). Criterion A1 (inattention) is not met for the past 6 months. g. Often loses things necessary for tasks or activities (e.g., school materials, pen-cils, books, tools, wallets, keys, Specify if: in partial remission: When full criteria were previously met, fewer paperwork, eyeglasses, mobile telephones). than the full criteria have been met for the past 6 months, and the h. Is often easily distracted by extraneous stimuli (for older symptoms still result in impairment in social, academic, or adolescents and adults, may include unrelated thoughts) occupational functioning. i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, Specify current severity: returning calls, paying bills, keeping appointments). Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. 2. Hyperactivity and impulsivity: Six (or more) of the following Moderate: Symptoms or functional impairment between "mild" and symptoms have persisted for at least 6 months to a degree "severe" are present. that is inconsistent with developmental level and that Severe: Many symptoms in excess of those required to make the negatively impacts directly on social and academic or diagnosis, or several symptoms that are particularly severe, are occupational activities: present, or the symptoms result in marked impairment in social or Note: The symptoms are not solely a manifestation of occupational functioning. oppositional behavior, defi-ance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required ASSOCIATED FEATURES SUPPORTING DIAGNOSIS a. Often fidgets with or taps hands or feet or squirms in Mild delays in language, motor, or social development seat. often co occur b. Often leaves seat in situations when remaining seated is Associated features may include low frustration tolerance, expected (e.., leaves his or her place in the classroom, in irritability, or mood lability the office or other workplace, or in other situations that Academic or work performance is often impaired require remaining in place). Individuals with ADHD may exhibit cognitive problems on c. Often runs about or climbs in situations where it is tests of attention, executive function, or memory, although inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) these tests are not sufficiently sensitive or specific to d. Often unable to play or engage in leisure activities quietly. serve as diagnostic indices e. Is often "on the go," acting as if "driven by a motor' (e.g., UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 3 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD By early adulthood, ADHD is associated with an Academic deficits, school-related problems, and peer increased risk of suicide attempt, primarily when neglect tend to be most associated with elevated comorbid with mood, conduct, or substance use symptoms of inattention, whereas peer rejection and, to a disorders. lesser extent, accidental injury are most salient with marked symptoms of hyperactivity or impulsivity. DEVELOPMENT AND COURSE ADHD is most often identified during elementary school DIFFERENTIAL DIAGNOSES years, and inattention becomes more prominent and Oppositional defiant disorder (ODD) impairing Intermittent explosive disorder (IED) The disorder is relatively stable through early ○ Serious aggression toward others adolescence, but some individuals have a worsened Other neurodevelopmental disorders course with development of antisocial behaviors ○ Tics and stereotypies Symptoms have been shown to persist into adolescence Specific learning disorder in 60-85% of cases, and into adult life in approximately Intellectual disability 60% of cases. The remaining 40% of cases may remit at Autism spectrum disorder puberty, or in early adulthood ○ ASD has fixations, tantrums, and irritability In most individuals with ADHD, symptoms of motoric Anxiety disorder hyperactivity become less obvious (fidgetiness or inner Mood disorder feeling of restlessness, jitteriness, or impatience) in Disruptive mood dysregulation disorder adolescence and adulthood, but difficulties with ○ Pervasive irritability and intolerance frustration inattention, poor planning, and impulsivity persist ○ Disorganized behavior isn’t a characteristic Persistence is predicted by a family history of the Reactive attachment disorder disorder, negative life events, and comorbidity with ○ Social inhibition conduct symptoms, depression, and anxiety disorders Substance use disorders When remission occurs, it is usually between the ages of ○ Usually comorbid with ADHD 12 and 20 Personality disorders Remission can be accompanied by a productive ○ Cluster B — adolescents and adults adolescence and adult life, satisfying interpersonal Psychotic disorders relationships, and few significant sequelae Medication induced symptoms of ADHD Most patients with the disorder, however, undergo partial Disordered sleep remission and are vulnerable to antisocial behavior, Sydenham's chorea substance use disorders, and mood disorders ○ Secondary to streptococcus infection FUNCTIONAL CONSEQUENCES COMORBIDITY ADHD is associated with reduced school performance In the general population, oppositional defiant disorder and academic attainment, social rejection, and, in adults, co-occurs with ADHD in approximately half of children poorer occupational performance, attainment, with the combined presentation and about a quarter with attendance, and higher probability of unemployment as the predominantly inattentive presentation well as elevated interpersonal conflict Conduct disorder co-occurs in about a quarter of children Children with ADHD are significantly more likely to or adolescents with the combined presentation, develop conduct disorder in adolescence and antisocial depending on age and setting personality disorder in adulthood, consequently Most children and adolescents with disruptive mood increasing the likelihood for substance use disorders and dysregulation disorder have symptoms that also meet incarceration criteria for ADHD; a lesser percentage of children with The risk of subsequent substance use disorders is ADHD have symptoms that meet criteria for disruptive elevated, especially when conduct disorder or antisocial mood dysregulation disorder personality disorder develops Specific learning disorder commonly co-occurs with Traffic accidents and violations are more frequent in ADHD drivers with ADHD Anxiety disorders and major depressive disorder occur in Inadequate or variable self-application to tasks that a minority of individuals with ADHD but more often than in require sustained effort is often interpreted by others as the general population laziness, irresponsibility, or failure to cooperate Intermittent explosive disorder occurs in a minority of Family relationships may be characterized by discord and adults with ADHD, but at rates above population levels negative interactions Although substance use disorders are relatively more Peer relationships are often disrupted by peer rejection, frequent among adults with ADHD in the general neglect, or teasing of the individual with ADHD population, the disorders are present in only a minority of In its severe form, the disorder is markedly impairing, adults with ADHD affecting social, familial, and scholastic/occupational In adults, antisocial and other personality disorders may adjustment co-occur with ADHD UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 4 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD Other disorders that may co-occur with ADHD include CHARACTERISTICS obsessive-compulsive disorder, tic disorders, and autism Clonidine and guanfacine, α2-adrenergic receptor spectrum disorder agonists and antihypertensives, are alternative medications that ameliorate ADHD symptoms—frequently DIAGNOSIS AND LAB EXAMINATION associated with aggression Comprehensive psychiatric and medical history Clonidine AE: cardiovascular complications, especially Prenatal, perinatal, and toddler information should be when combined with methylphenidate included Guanfacine appears to be less sedating and less apt to Complications of mother’s pregnancy cause hypotension than clonidine, and it has a longer Medical problems that may produce symptoms half-life overlapping with ADHD include petit mal epilepsy, More recently, a norepinephrine reuptake inhibitor, hearing and visual impairments, thyroid abnormalities, atomoxetine, with a usual half-life of 5 hours, was found and hypoglycemia to ameliorate ADHD behavior A thorough cardiac history should be taken, including an Atomoxetine may be beneficial in the treatment of investigation of the lifetime history of syncope, family nonresponders with the use of stimulants history of sudden death, and a cardiac examination of the Side effects such as anorexia and weight loss occur at child should be obtained, prior to treatment frequencies comparable to methylphenidate. Acute liver Physical examination, blood pressure, pulse, weight, and failure is a rare complication height should be taken before treatment and monitored Tricyclic antidepressants or selective serotonin reuptake No specific laboratory measures are pathognomonic of inhibitors (such as fluoxetine, sertraline, and paroxetine) ADHD may assist in hyperactivity management, particularly in the presence of depressed affect PHARMACOLOGIC TREATMENT Barbiturates, used for antiepileptic therapy, have a sedative effect and aggravate hyperactivity STIMULANT MEDICATIONS When this occurs, nonbarbiturate antiepileptic drugs Improve behavioral control, and permit a more adaptive should gradually be substituted disposition of attention in relation to the demands of the Methylxanthines such as caffeine and theophylline do not moment appear to have adverse behavioral effects in children. Methylphenidate They may even have a mild positive effect on some ○ Inhibits receptor uptake of dopamine by blocking externalizing behaviors the dopamine transporter (DAT1) Increases dopamine level ○ Optimal doses range between 10-50 mg per day ○ The long-acting methylphenidate preparation (Ritalin sustained release) is effective for approximately 6 hours ○ Other recently introduced long-acting methylphenidate preparations are trademarked as Concerta, Ritalin-LA, and Metadate CD, and their duration of action is in the 8-12 hour range ○ Assists performance by helping sustained attention, diminishing impulsiveness, and improving inhibition of hasty incorrect responses Pemoline Modafinil ○ CNS stimulant made for narcolepsy (daytime sleepiness) ○ Needs FDA approval as it may cause skin rash ALTERNATIVES Despiramine or risperidone Dexedrine NON-PHARMACOLOGIC TREATMENT Clonidine and guanfacine Avoid factors that might precipitate hyperactive behavior: Tricyclic antidepressants or Selective serotonin reuptake fluorescent lighting; heavy metals; certain natural foods, inhibitors notably sugar; and certain food additives, especially dyes Norepinephrine Psychosocial interventions for children with ADHD reuptake inhibitor include psychoeducation, academic organization skills Barbiturates remediation, parent training, behavior modification in the Methylxanthines classroom and at home, cognitive behavioral therapy (CBT), and social skills training UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 5 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD Another goal of therapy is to help parents of children with OPPOSITIONAL DEFIANT DISORDER (ODD) ADHD recognize and promote the notion that, although Enduring patterns of negativistic, disobedient, and hostile the child may not “voluntarily” exhibit symptoms of ADHD, behavior toward authority figures, as well as an inability to he or she is still capable of being responsible for meeting take responsibility for mistakes, leading to placing blame reasonable expectations on others, but in the absence of serious violations of the Short courses of supportive psychotherapy can help to rights of others reduce intrafamily tensions that aggravate, or sometimes ○ Different from conduct disorder even precipitate, restless and impulsive behavior Frequently argue with adults and become easily annoyed Group therapy aimed at both refining social skills and by others, leading to a state of anger and resentment increasing self-esteem and a sense of success may be May have difficulty in the classroom and with peer very useful for children with ADHD who have great relationships, but generally do not resort to physical difficulty functioning in group settings, especially in school aggression or significantly destructive behavior A multimodality regime including intensive psychotherapy reduced the incidence of antisocial behavior in an ADHD PREVALENCE cohort Although oppositional defiant disorder can begin as early Rational management of children who are not relieved of as 3 years of age, it typically is noted by 8 years of age their disability by medication rests on individual attention, and usually not later than early adolescence frequent and consistent reward of socially acceptable The prevalence of oppositional defiant disorder ranges behavior, consistent limit setting, and the gradual phasing from 1-11%, with an average prevalence estimate of in of material to be learned around 3.3% In general, behavioral therapy should be an adjunct to The disorder appears to be somewhat more prevalent in effective stimulant therapy rather than the only treatment males than in females (1.4:1) prior to adolescence The prevalence of oppositional defiant behavior in males PROGNOSIS and females diminishes in youth older than 12 years of Whereas the overt restlessness of hyperactive children age diminishes in adolescence, their impulsiveness and emotional lability usually persist, with a correspondingly RISK FACTORS mixed prognosis for long-term adaptive outcome Temperamental Adults who had ADHD in childhood often continue to ○ Temperamental factors related to problems in show functional impairment emotional regulation (e.g., high levels of When aggressiveness is a feature, it particularly tends to emotional reactivity, poor frustration tolerance) persist and appears to bear some association with early have been predictive of the disorder onset alcoholism Environmental Schizophrenia is not a major ADHD outcome. However, ○ Harsh, inconsistent, or neglectful child-rearing children of schizophrenic mothers, at high risk for adult practices are common in families of children and schizophrenia, have been found to be prone to attentional adolescents with oppositional defiant disorder, dysfunction and poor social competence and these parenting practices play an important role in many causal theories of the disorder Genetic and physiological ○ A number of neurobiological markers (e.g., lower heart rate and skin conductance reactivity; reduced basal cortisol reactivity; abnormalities in the prefrontal cortex and amygdala) have been associated with oppositional defiant disorder ETIOLOGY Pathology begins when this oppositional behavior persists abnormally, authority figures overreact, or oppositional behavior recurs considerably more frequently than in most children of the same mental age ○ Opposition is normal at 18-24 months (terrible 2) ODD persists abnormally Irritability appears to be the one most predictive of later psychiatric disorders, whereas the other elements may be considered components of temperament UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 6 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD TYPES Argumentative/Defiant Behavior Angry/Irritable 4. Often argues with authority figures or, for children and ○ Often lose their tempers, are easily annoyed, adolescents, with adults and feel irritable much of the time 5. Often actively defies or refuses to comply with requests from ○ Can progress to CD authority figures or with rules 6. Often deliberately annoys others Argumentative/Defiant 7. Often blames others for his or her mistakes or misbehavior ○ Display a pattern of arguing with authority figures, and adults such as parents, teachers, Vindictiveness and relatives 8. Has been spiteful or vindictive at least twice within the past 6 ○ Children actively refuse to comply with requests, months deliberately break rules, and purposely annoy others Note: The persistence and frequency of these behaviors should be ○ They often do not take responsibility for their used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, actions, and often blame others for their the behavior should occur on most days for a period of at least 6 misbehavior months unless otherwise noted (Criterion A8). For individuals 5 Vindictive years or older, the behavior should occur at least once per week ○ Vindictive or spiteful actions at least twice in 6 for at least 6 months, unless otherwise noted (Criterion A8). While months to meet diagnostic criteria these frequency criteria provide guidance on a minimal level of ○ Can progress to CD frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual's CLINICAL FEATURES developmental level, gender, and culture Typically, symptoms of the disorder are most evident in interactions with adults or peers whom the child knows B. The disturbance in behavior is associated with distress in the well individual or others in his or her immediate social context (e.g., The symptoms of oppositional defiant disorder may be family, peer group, work colleagues), or it impacts negatively on confined to only one setting, and this is most frequently social, educational, occupational, or other important areas of the home functioning Although children with oppositional defiant disorder may be aware that others disapprove of their behavior, they C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the may still justify it as a response to unfair or unreasonable criteria are not met for disruptive mood dysregulation disorder circumstances ○ Don’t accept own mistake Specify current severity: Chronic oppositional defiant disorder or irritability almost Mild: Symptoms are confined to only one setting (e.g., at home, at always interferes with interpersonal relationships and school, at work, with peers) school performance Moderate: Some symptoms are present in at least two settings These children are often rejected by peers, and may Severe: Some symptoms are present in three or more settings become isolated and lonely Despite adequate intelligence, they may do poorly or fail DIFFERENTIAL DIAGNOSIS in school, due to their lack of cooperation, poor Conduct Disorder participation, and inability to accept help ○ ODD is less severe and has no destruction of Secondary to these difficulties are low self-esteem, poor people, animals, properties frustration tolerance, depressed mood, and temper ADHD outbursts ○ Lose focus in attention in general Adolescents who are ostracized may turn to alcohol and ○ ODD just don’t want to conform illegal substances as a modality to fit in with peers Mood Disorder Children who are chronically irritable often develop mood ○ Episodic disorders in adolescence or adulthood Disruptive Mood Dysregulation Disorder ○ Severity and frequency of outbursts are more ODD severe Intermittent Explosive Disorder Diagnostic Criteria ○ Serious aggression toward others A. A pattern of angry/irritable mood, argumentative/defiant behavior, or Intellectual Disability vindictiveness lasting at least 6 months as evidenced by at least ○ If oppositional behavior is comparable to those four symptoms from any of the following categories, and exhibited of the same age during interaction with at least one individual who is not a sibling Language Disorder ○ Cannot follow because they don’t understand Angry/Irritable Mood 1. Often loses temper Social Anxiety Disorder 2. Is often touchy or easily annoyed ○ Fear of having negative evaluation 3. Is often angry and resentful UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 7 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD COMORBIDITY In the therapeutic relationship, the child can learn new ADHD strategies to develop a sense of mastery and success in Anxiety Disorder social situations with peers and families Mood Disorder In the safety of a more “neutral” relationship, children may discover that they are capable of less provocative behavior COURSE AND PROGNOSIS Often, self-esteem must be restored before a child with The course of oppositional defiant disorder depends on oppositional defiant disorder can make more positive the severity of the symptoms and the ability of the child to responses to external control develop more adaptive responses to authority Replacing harsh, punitive parenting and increasing Oppositional defiant disorder often precedes the positive parent-child interactions may positively influence development of conduct disorder, especially for those the course of oppositional and defiant behaviors with the childhood-onset type of conduct disorder ○ ODD → CD → antisocial personality disorder The stability of oppositional defiant disorder varies over time, with approximately 25% of children with the disorder no longer meeting diagnostic criteria Persistence of oppositional defiant symptoms poses an increased risk of additional disorders, such as anxiety disorders, mood disorders, conduct disorder and substance use disorders The defiant, argumentative, and vindictive symptoms carry most of the risk for conduct disorder, whereas the angry-irritable mood symptoms carry most of the risk for emotional disorders Positive outcomes are more likely for intact families who can modify their own expression of demands and give less attention to the child’s argumentative behaviors. In children who have a long history of aggression and oppositional defiant disorder, there is a greater risk of the development of conduct disorder and later substance use disorders Parental psychopathology, such as antisocial personality disorder and substance abuse, appears to be more common in families with children who have oppositional defiant disorder, which creates additional risks for chaotic and troubled home environments The prognosis for oppositional defiant disorder in a child depends somewhat on family functioning and the development of comorbid psychopathology TREATMENT The primary treatment of oppositional defiant disorder is family intervention using both direct training of the parents in child management skills and careful assessment of family interactions The goals of this intervention are to reinforce more prosocial behaviors and to diminish undesired behaviors at the same time Cognitive behavioral therapists emphasize teaching parents how to alter their behavior to discourage the child’s oppositional behavior by diminishing attention to it, and encourage appropriate therapy focuses on selectively reinforcing and praising appropriate behavior and ignoring or not reinforcing undesired behavior Children with oppositional defiant behavior may also benefit from individual psychotherapy in which they role play and “practice” more adaptive responses UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 8 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD CONDUCT DISORDER (CD) ○ The disorder also appears to be more common Children who develop enduring patterns of aggressive in children of biological parents with severe behaviors that begin in early childhood and violate the alcohol use disorder, depressive and bipolar basic rights of peers and family members disorders, or schizophrenia or biological parents Youth with conduct disorder often demonstrate behaviors who have a history of ADHD or conduct disorder in the following four categories: Slower resting heart rate has been reliably noted in ○ Physical aggression or threats of harm to people individuals with conduct disorder compared with those ○ Destruction of own property or that of others without the disorder, and this marker is not characteristic ○ Theft or acts of deceit of any other mental disorder ○ Frequent violation of age-appropriate rules Reduced autonomic fear conditioning, particularly low Conduct disorder is associated with many other skin conductance, is also well-documented psychiatric disorders including ADHD, depression, and Structural and functional differences in brain areas learning disorders associated with affect regulation and affect processing, ○ It is also associated with certain psychosocial particularly frontotemporal-limbic connections involving factors, including childhood maltreatment, harsh the brain's ventral prefrontal cortex and amygdala, have or punitive parenting, family discord, lack of been consistently noted in individuals with conduct appropriate parental supervision, lack of social disorder competence, and low socioeconomic level NEUROBIOLOGICAL FACTORS PREVALENCE Studies have reported that children with conduct disorder One-year population prevalence estimates range from had decreased gray matter in limbic brain structures, and 2% to more than 10%, with a median of 4% in the bilateral anterior insula and left amygdala Ratio of conduct disorder in males compared to females compared to healthy controls ranges from 4:1 to as much as 12:1 Neurotransmitter studies in children with conduct Conduct disorder occurs with greater frequency in the disorder, suggest low levels of plasma dopamine children of parents with antisocial personality disorder -hydroxylase, an enzyme that converts dopamine to and alcohol dependence than in the general population norepinephrine, leading to a hypothesis of decreased The prevalence of conduct disorder and antisocial noradrenergic functioning in conduct disorder. Other behavior is associated with socioeconomic factors, as studies of conduct- disordered juvenile offenders have well as parental psychopathology found high plasma serotonin levels in blood. Evidence indicates that blood serotonin levels correlate inversely RISK FACTORS with levels of 5-HIAA in the cerebrospinal fluid (CSF) and that low 5-HIAA levels in CSF correlate with aggression Temperamental and violence ○ Temperamental risk factors include a difficult EEG undercontrolled infant temperament and ○ Aggressive children had significantly greater lower-than-average intelligence, particularly with relative right frontal brain activity at rest regard to verbal IQ compared with nonaggressive children Environmental ○ Family-level risk factors include parental rejection and neglect, inconsistent child-rearing CLINICAL FEATURES practices, harsh discipline, physical or sexual The onset of conduct disorder may occur as early as the abuse, lack of supervision, early institutional preschool years, but the first significant symptoms usually living, frequent changes of caregivers, large emerge during the period from middle childhood through family size, parental criminality, and certain middle adolescence kinds of familial psychopathology (e.g., The average age of onset of conduct disorder is younger substance-related disorders) in boys than in girls. Boys most commonly meet the ○ Community-level risk factors include peer diagnostic criteria by 10-12 years, whereas girls often rejection, association with a delinquent peer reach 14-16 years before the criteria are met. group, and neighborhood exposure to violence Aggressive antisocial behavior can take the form of Chronic exposure to violence in the media including bullying, physical aggression, and cruel behavior toward television, video games, and music videos has been peers shown to promote lower levels of empathy in children, Children may be hostile, verbally abusive, impudent, which may add a risk factor for the development of defiant, and negativistic toward adults aggressive behavior Persistent lying, frequent truancy, and vandalism are Genetic and physiological common. In severe cases, destructiveness, stealing, and ○ The risk is increased in children with a biological physical violence often occur or adoptive parent or a sibling with conduct Sexual behavior and regular use of tobacco, liquor, or disorder illicit psychoactive substances begin unusually early for such children and adolescents UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 9 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD Suicidal thoughts, gestures, and acts are frequent in in social, academic, or occupational functioning children and adolescents with conduct disorder who are in conflict with peers, family members, or the law and are C. If the individual is age 18 years or older, criteria are not met for unable to problem solve their difficulties antisocial personality disorder Some children with aggressive behavioral patterns have Specify whether: impaired social attachments 312.81 (F91.1) Childhood-onset type: Individuals show at least one Many children with conduct problems have poor symptom char- acteristic of conduct disorder prior to age 10 years. self-esteem, although they may project an image of 312.82 (F91.2) Adolescent-onset type: Individuals show no toughness symptom characteristic of conduct disorder prior to age 10 years. They may lack the skills to communicate in socially 312.89 (F91.9) Unspecified onset: Criteria for a diagnosis of acceptable ways and appear to have little regard for the conduct disorder are met, but there is not enough information feelings, wishes, and welfare of others available to determine whether the onset of the first symptom was before or after age 10 years. Children and adolescents with conduct disorders often feel guilt or remorse for some of their behaviors, but try to Specify if: blame others to stay out of trouble With limited prosocial emotions: To qualify for this specifier, an In other cases, conduct disorder includes repeated individual must have displayed at least two of the following truancy, vandalism, and serious physical aggression or characteristics persistently over at least 12 months and in multiple assault against others by a gang, such as mugging, gang relationships and settings. These characteristics reflect the fighting, and beating individual's typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple CD information sources are necessary. In addition to the individual's self-report, it is necessary to consider reports by others who have Diagnostic Criteria known the individual for extended periods of time (e.g., parents, A. A repetitive and persistent pattern of behavior in which the basic teachers, co-workers, extended family members, peers) rights of others or ma- jor age-appropriate societal norms or rules Lack of remorse or guilt: Does not feel bad or guilty when he or are violated, as manifested by the presence of at least three of the she does something wrong (exclude remorse when expressed only following 15 criteria in the past 12 months from any of the when caught and/or facing punishment). The individual shows a categories below, with at least one criterion present in the past 6 general lack of concern about the negative consequences of his or months: her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules Aggression to People and Animals Callous–lack of empathy: Disregards and is unconcerned about the 1. Often bullies, threatens, or intimidates others feelings of others. The individual is described as cold and uncaring. 2. Often initiates physical fights The person appears more concerned about the effects of his or her 3. Has used a weapon that can cause serious physical harm to actions on himself or herself, rather than their effects on others, even others (e.g., a bat, brick, broken bottle, knife, gun) when they result in substantial harm to others 4. Has been physically cruel to people Unconcerned about performance: Does not show concern about 5. Has been physically cruel to animals poor/problematic performance at school, at work, or in other 6. Has stolen while confronting a victim (e.g., mugging, purse important activities. The individual does not put forth the effort snatching, extortion, armed robbery) necessary to perform well, even when expectations are clear, and 7. Has forced someone into sexual activity typically blames others for his or her poor performance Shallow or deficient affect: Does not express feelings or show Destruction of Property emotions to others, except in ways that seem shallow, insincere, or 8. Has deliberately engaged in fire setting with the intention of superficial (e.g., actions contradict the emotion displayed; can turn causing serious damage emotions "on" or "of" quickly) or when emotional expressions are 9. Has deliberately destroyed others' property (other than by fire used for gain (e.g., emotions displayed to manipulate or intimidate setting) others) Deceitfulness or Theft Specify current severity: 10. Has broken into someone else's house, building, or car Mild: Few if any conduct problems in excess of those required to 11. Often lies to obtain goods or favors or to avoid obligations (i.e., make the diagnosis "cons" others) are present, and conduct problems cause relatively minor harm to 12. Has stolen items of nontrivial value without confronting a victim others (e.g., lying, truancy, staying out after dark without permission, (e.g., shoplifting, but without breaking and entering; forgery) other rule-breaking) Moderate: The number of conduct problems and the effect on others Serious Violations of Rules are intermediate between those specified in "mild" and those in 13. Often stays out at night despite parental prohibitions, "severe" (e.g., stealing without confront- ing a victim, vandalism) beginning before age 13 years Severe: Many conduct problems in excess of those required to make 14. Has run away from home overnight at least twice while living in the diagnosis are present, or conduct problems that cause the parental or parental surrogate home, or once without considerable harm to others (e.g., forced sex, physical cruelty, use of returning for a lengthy period a weapon, stealing while confronting a victim, breaking and entering) 15. Is often truant from school, beginning before age 13 years B. The disturbance in behavior causes clinically significant impairment UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 10 OT1026 SHIFT #1 | LESSON #5 | ADHD, ODD, and CD GENDER-RELATED DIAGNOSTIC ISSUES ANTISOCIAL PERSONALITY DISORDER (ASPD) Males with a diagnosis of conduct disorder frequently Diagnostic Criteria exhibit fighting, stealing, vandalism, and school discipline problems A. A pervasive pattern of disregard for and violation of the rights of Females with a diagnosis of conduct disorder are more others, occurring since age 15 years, as indicated by three (or likely to exhibit lying, truancy, running away, substance more) of the following: use, and prostitution 1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are Whereas males tend to exhibit both physical aggression grounds for arrest and relational aggression (behavior that harms social 2. Deceitfulness, as indicated by repeated lying, use of aliases, relationships of others), females tend to exhibit relatively or conning others for personal profit or pleasure more relational aggression 3. Impulsivity or failure to plan ahead 4. Irritability and aggressiveness, as indicated by repeated DIFFERENTIAL DIAGNOSES physical fights or assaults 5. Reckless disregard for safety of self or others Oppositional Defiant Disorder 6. Consistent irresponsibility, as indicated by repeated failure to ADHD sustain consistent work behavior or honor financial obligations Mood Disorder 7. Lack of remorse, as indicated by being indifferent to or Intermittent Explosive Disorder rationalizing having hurt, mistreated, or stolen from another Adjustment Disorder B. The individual is at least 18 years old COMORBID FACTORS C. There is evidence of conduct disorder with onset before 15 years ADHD and oppositional defiant disorder are both common in individuals with conduct disorder, and this D. The occurrence of antisocial behavior is not exclusively during the comorbid presentation predicts worse outcomes course of schizophrenia or bipolar disorder Individuals who show the personality features associated with antisocial personality disorder often violate the basic TREATMENT rights of others or violate major age-appropriate societal Cognitive behavioral therapy norms, and as a result their pattern of behavior often Atypical antipsychotics meets criteria for conduct disorder ○ Risperidone (Risperdal), olanzapine (Zyprexa), Conduct disorder may also co-occur with one or more of quetiapine (Seroquel), ziprasidone (Geodon), the following mental disorders: specific learning disorder, and aripiprazole (Abilify) anxiety disorders, depressive or bipolar disorders, and ○ Side effects of second-generation antipsychotics substance-related disorders include sedation, increased prolactin levels, (with risperidone use) and extrapyramidal COURSE AND PROGNOSIS symptoms, including akathisia In a majority of individuals, the disorder remits by Clonidine (Catapres) may decrease aggression adulthood. Many individuals with conduct ○ Alpha 2 agonist disorder—particularly those with adolescent-onset type SSRIs and those with few and milder symptoms—achieve ○ Fluoxetine (Prozac), sertraline (Zoloft), adequate social and occupational adjustment as adults paroxetine (Paxil), and citalopram (Celexa), are The course and prognosis for children with conduct used clinically to target symptoms of impulsivity, disorder is most guarded in those who have symptoms at irritability, and mood lability, which frequently a young age, exhibit the greatest number of symptoms, accompany conduct disorder and the most severe, and express them most frequently. They have increased risk of criminal behavior, conduct disorder, and substance-related disorders in adulthood The best prognosis is predicted for mild conduct disorder in the absence of coexisting psychopathology and the presence of normal intellectual functioning UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS 11