ADHD, OCD, OD AND BULLY.ppt (Psychiatry)

Attention deficit hyperactivity disorder , Obsessive Compulsive Disorder, Oppositional disorder and Bully

1. ADHD, CD, ODD
& Bullying
behaviour
DR HEMA MALINI PALANIASAMY
PAKAR PSIKIATRI
KETUA JABATAN PSIKIATRI DAN KESIHATAN MENTAL,
HOSPITAL KUALA LIPIS, PAHANG.

2. ADHD

3. Hyperactivity / impulsivity
(6 or more symptoms , for at least 6 months)
Often leaves seat in classroom or situations
when remaining seated is expected
Runs or climbs excessively in situations which
is inappropriate
Difficulty playing or engaging in leisure
activities quietly
Often ‘on the go’
Blurts out answers before questions been
completed
Often interrupts or intrudes on others
Difficulty waiting for turns

4. Inattention
(6 or more symptoms , for at least 6 months)

Fails to give close attention to details
Difficulty in sustaining attention
Fails to finish or complete task
Often avoid to engage in tasks that require
sustained mental effort
Difficulty organizing task
Loses things
Easily distracted
Forgetful

5. before 7 years old
presence in two or more settings
impairment in function
do not occur exclusively during the course of a
PDD, schizophrenia or other psychotic disorder &
are not better accounted for by another mental
disorder

6. Subtypes
Predominantly Hyperactive-impulsive
Predominantly Inattentive
Combined

7. Preschool
children
School age
children
Adolescents(70-80%)
Adults
(50-60%)
Hyperactivity
Inattention
tantrum
School-related problem
poor academic achievement
Conduct, oppositional & defiant
ADHD symptoms
Conduct ,oppositional & defiant
Substance abuse
ADHD symptoms
job-related problem
Antisocial personality

8. Diagnostic assessment
ADHD is a clinical diagnosis
- comprehensive
history(parents or other carer,
teachers, etc.) & MSE
- school report, home &
school visit, home video
- physical examination

10. Differential diagnosis
Mental retardation
Autistic Disorder
Emotional problem eg. anxiety disorders, mood
disorder
Psychosocial problems eg. child abuse, divorce,
grief
Traumatic brain injury
Medical conditions eg. epilepsy

11. Comorbid conditions
Oppositional defiant disorder(ODD)
Conduct disorder(CD)
Specific Learning Disorder
Tics Disorder
Depression
Anxiety
Enuresis
Substance abuse

12. Aetiology
Genetic
- twin studies showed heritability of 76%
(Faraone et.al. 2005b)
- ass. with markers at chromosome 4,5,6,8,11
16 & 17 (Muenke 2004, Smalley et.al. 2004)
- sig ass with ADHD;D4,D5,dopamine
transporter, enzyme dopamine B-hydroxylase,
serotonin transporter gene, serotonin 1B
receptor, synaptosomal-associated protein 25
gene (Faraone et.al. 2005b)

Biolcal factors
- Globally decreased brain volume (Krain &
Castellanos 2006)
- frontal lobe volume, basal ganglia structures &
cerebellum (Castellanos et.al. 2002)
- Less brain electrical activity
- Dopamine, adrenaline & noradrenaline
neurotransmitters

13. Neurobiological
- reduced cortical white & grey matter (Castellanos
et.al. 2000)
- decreased frontal & temporal lobe volumes (Sowell
et.al. 2003)
- when patients with ADHD perform tasks requiring
inhibitory control, differences in brain activation
compared to controls found in caudate, frontal lobe
& anterior cingulate (Bush et.al. 2005)

14. Neuropsychological
- deficits in executive functions such as
- response inhibition, vigilance, working
memory, planning (Willcutt et.al. 2005)
Other risk factors
- brain injury, hypoxia, infection
- maternal smoking & alcohol consumption
- perinatal stress, low birth weight, toxin

15. Management of ADHD
Preschool-aged children (4-5 years)
- behaviour therapy
- medication in moderate-to-severe impairment in function &
behaviour therapy do not provide significant improvement
School-aged children(6-11 years) & adolescents
- medication & behaviour therapy
ADHD:CPG for the diagnosis, evaluation, and Treatment of ADHD
in Children and Adolescents.Pediatrics,128(5),2011.

16. A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity
Disorder. The MTA Cooperative Group
Arch Gen Psychiatry. 1999;56(12):1073-1086.doi:10.1001/archpsyc.56.12.1073
Background Previous studies have demonstrated the short-term efficacy of pharmacotherapy and
behavior therapy for attention-deficit/hyperactivity disorder (ADHD), but no longer-term (ie, >4 months)
investigations have compared these 2 treatments or their combination.
Methods A group of 579 children with ADHD Combined Type, aged 7 to 9.9 years, were assigned to 14
months of medication management (titration followed by monthly visits); intensive behavioral treatment
(parent, school, and child components, with therapist involvement gradually reduced over time); the
two combined; or standard community care (treatments by community providers). Outcomes were
assessed in multiple domains before and during treatment and at treatment end point (with the
combined treatment and medication management groups continuing medication at all assessment
points). Data were analyzed through intent-to-treat random-effects regression procedures.
Results All 4 groups showed sizable reductions in symptoms over time, with significant differences among
them in degrees of change. For most ADHD symptoms, children in the combined treatment and
medication management groups showed significantly greater improvement than those given intensive
behavioral treatment and community care. Combined and medication management treatments did
not differ significantly on any direct comparisons, but in several instances (oppositional/aggressive
symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading
achievement) combined treatment proved superior to intensive behavioral treatment and/or
community care while medication management did not. Study medication strategies were superior to
community care treatments, despite the fact that two thirds of community-treated subjects received
medication during the study period.
Conclusions For ADHD symptoms, our carefully crafted medication management was superior to
behavioral treatment and to routine community care that included medication. Our combined
treatment did not yield significantly greater benefits than medication management for core ADHD
symptoms, but may have provided modest advantages for non-ADHD symptom and positive
functioning outcomes.

17. Medications approved by
the FDA
for ADHD
Methylphenidate preparations
eg. Ritalin, Concerta
Amphetamine preparations

SNRI
eg. Atomoxetine

18. Common side-effects
What are the common side-effects of
methylphenidate?
What are the common side-effects of
atomoxetine?

19. Less common but important
side-effects
Stimulants
- risk of sudden death in preexisting heart disease, or symptoms
suggestive of sig CVS such as fainting, exercise intolerance,
palpitation, or strong FH of sudden death
- tetralogy of Fallot, coronary artery abnormalities, subaortic
stenosis
- psychotic symptoms
Straterra
- suicidal ideation

20. Medications used for
ADHD,
not approved by FDA
Antidepressants
eg. Bupropion, Imipramine, Nortryptiline
Alpha2-Adrenergic agonists
eg. Clonidine, Guanfacine

21. Non-pharmacological
management
Psychoeducation
Parent training & behavioural interventions
School based intervention
Occupational therapy
Special education
Support group

22. What is the role of diet?
Limited evidence to support role of diet in causing
ADHD symptoms

23. Course & outcome
70-80% continue to have symptoms in
adolescence
50-60% continue to have symptoms in adult

24. ADHD
Oppositional Defiant
Disorder
Conduct Disorder
Antisocial personality
disorder

25. Outcome
Higher risk of substance abuse,
antisocial behaviour, other psychiatric
disorders
Less schooling & lower status job
Factors associated with poor outcome:
- severe symptoms
- predominantly hyperactive/impulsivity
- early conduct disorder
- negative life-events

26. Early detection and
intervention!

27. ODD, CD &
Bullying
behaviour

28. ODD (Oppositional defiant
disorder)
A pattern of negativistic, hostile & defiant
behaviour lasting at least 6 months(4 or more):
Angry/irritable mood
loses temper
touch or easily annoyed by others
angry & resentful

29. Argumentative/defiant behaviour
argues with adults
defies or refuses to comply with adults
request deliberately annoys people
blames other
Vindictiveness
spiteful & vindictive

30. Frequency & intensity of behaviours are non-
normative given the individual ‘s developmental
level, gender & culture
<5 years : most days for a period of at least 6
months
>=5 years: once per week for at least 6 months

31. Remove exclusionary criteria for CD
Organize symptoms to distinguish emotional &
behavioural symptoms; emotional symptoms
contribute uniquely to emotional disorders
Severity index based on cross-situation
pervasiveness of the symptoms eg. those met
criteria by both teachers & parents show greater
impairment

32. CD Conduct disorder
A repetitive & persistent pattern of behaviour in which basic
rights of others or major age-appropriate societal norms or
rules are violated, 3 or more criteria in the past 12 months, with
at least one criterion present in the past six months:
 Aggression to people & animals
bullies, threatens or intimidate others
initiates physical fight

33. used weapon that cause serious physical
harm to others
Physically cruel to people
Physically cruel to animals
Stolen while confronting a victim
 Destruction of property
deliberately engaged in fire setting with
intention of causing serious damage
deliberately destroyed others’ property

34.  Deceitfulness or theft
broken into someone else’s house,
building or car
lies to obtain goods or favours or to avoid
obligations
stolen items of nontrivial value without
confronting a victim

35. Serious violations of rules
stays out at night despite parental
prohibitions beginning before age 13 years
run away from home overnight at least
twice while living in a parental or parental
surrogate home
truant from school before age 13 years old
Childhood onset(<10 yrs) vs adolescent onset

37. Management of
ODD & CD

38. Individual intervention
CBT approach
Problem-solving Skills Training(PSST)
(Spivak & Shure 1974,1976,1978)
- targets antisocial & prosocial behaviour
- improving communication skills, problem-
solving skills, impulse control & anger
management

39. Family intervention
parent education
parent intervention to improve
- parenting skills & to manage behaviour of
the child effectively
- disciplining & age-appropriate
supervision

40. use of contingency management method
- reduce positive reinforcement of disruptive
behaviour
- increase reinforcement of prosocial &
compliant behaviour
- apply consequences and/or punishment of
disruptive behaviour
- make parental response predictable,
contingent & immediate

41. School intervention

Contingency management to encourage
positive behaviour & reduce negative
behaviour

42. Peer intervention
 to replace deviant peer group with socially
appropriate group
 to promote prosocial interactions with peers at
school

43. Other interventions
Community intervention
intervention with other agencies eg. Social
Welfare
Residential treatment
Treatment foster care
Medications for comorbid conditions

44. Individualized treatment plan
Multimodal treatment
Short-term improvement

45. Prevention

46. Bullying and ADHD

47. Bullying behaviour
Bullying refers to ‘repeated ill-negative behaviour
by one or more students directed against a
student who has difficulty defending him or
herself’ (Olweus 1978)

48. Significant association
with ADHD
Bullying & being bullied are significantly
associated with ADHD
ADHD is the commonest psych disorder among
bullies, & common among victims (Kumpulainen
et.al. 2001)
Bullying is associated with low self-control but
being bullied is not, rather the correlates of ADHD
such as poor social skills(Unnever & Cornell 2003)

49. Bullying & ADHD?
Impulsivity, hyperactivity, strong need to dominate are
correlates of both bullying & ADHD
Children with ADHD are more likely to bully
because of low self-control (Unnever &
Cornell 2003)
CD rather than hyperactivity or impulsivity as a significant
predictor for bullying(Perren et.al. 2006)

50. Being bullied & ADHD?
ADHD features such as disruptive, talkative &
impulsive may provoke bullies(Kumpulainen et.al.
2001, Unnever & Cornell 2003)
Perceived as ‘different’ thus become target of
bullies(Steer 2003)

51. •Early detection and treatment of ADHD may
prevent children from bullying others and/or
being bullied

52. Conclusions
•Early detection & treatment is important as
effective treatments of ADHD are available
•Psychoeducation is an essential part of the
management
•Prevention plays important role

53. References
Management of ADHD in children and adolescents.
Clinical practice guidelines Oct 2008
Practice Parameter for the Assessment and
Treatment of Children and Adoelscents With
Attention-Deficit/Hyperactivity Disorder. Focus, 2008,
VI(3),401-426.
Russel A. Barkley. Taking charge of ADHD. The
Guilford Press 2005.
Castellanos FX, Lee PP, Sharp W et.al. Developmental
trajectories of brain volume abnormalities in children and
adolescents with attention deficit/hyperactivity disorder. JAMA
2002,288:1740-1748.
Bush G, Valera EM, Seidman LJ. Functional neuroimaging of
attention-deficit/hyperactivity disorder: a review and suggested
future directions. Biol Psychiatry 2005, 57:1273-1284.

54. Muenke M. Heterogeneity underlying suggestive
linkage of ADHD in a genetic isolate. Presented at
the 51
st
Annual Meeting of the American Academy
of Child and Adolescent Psychiatry, Washington DC,
Oct 2004
 Smalley SL, Ogdie MN, McCough J, et.al.Genome
wide studies in attention deficit hyperactivity
disorder. Presented at the 51
st
Annual Meeting of
the American Academy of Child and Adolescent
Psychiatry, Washington DC, Oct 2004
Sowell ER, Thompson PM, Welcome SE, Henkenius AL,
Toga AW, Peterson BS.Cortical abnormalities in
children and adoelscents with attention-deficit
hyperactivity disorder. Lancet 2003, 362:1699-1707.

55. Olweus D, 1978. Aggression in schools:Bullies and whipping
boys.New York:Wiley. Unnever & Cornell
Kumpulainen K, Rasanen E, Puura K. Psychiatric disorders
and the use of meantl health services among children
involved in bullying. Aggressive Behaviour 2001, 27:102-110.
Perren S, Von Wyl A, Stadelmann S, Burgin D,Von Klitzing K.
Association between behavioural /emotional difficulties in
kindergarden children and the quality of their peer
relationships. Journal of the American Academ of Child
and Adolescent Psychiatry 2006, 45(7): 867-876.
Steer C. Bullying, bully or bullied(online).
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