UG ADHD,CD presentation for UG students.

UG ADHD,CD presentation for UG students.

1. ADHD, CD,ODD DR SHAHAFAS ALI Dept of Psychiatry TOMCH

2. INTRODUCTION Attention deficit hyperactivity disorder (ADHD) is defined as a pattern of inattentive and hyperactive impulsive behavior inconsistent with developmental level which interferes with functioning in social, educational or work setting. Chronic disorder which can cause impairment into adolescence and adulthood . Core symptoms - selective inattention, sustained attention , hyperactive symptoms and impulsive symptoms.

3. ETIOLOGY Highly heritable condition ( upto 75%) . Identified about 25- 45 genes based on genome- wide scans. DAT1 and DRD4 genes are commonly implicated. 2 to 8 times increased risk in siblings and parents of ADHD. Prematurity is an important factor. Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbidity. Imaging studies have detected differences in the neural structure. Brain maturation appears delayed and structural and functional connectivity are affected. Dopaminergic pathways are implicated. Underlying hypothesis - yet to be developed .

4. Traditionally, a childhood disorder but this perspective is rapidly changing with ADHD now being seen also as a major psychiatric disorder of adults . Classic form of ADHD - Onset by 7 years . Synapses rapidly increase in prefrontal cortex by age six and up to half of them are rapidly eliminated by adolescence . Timing of onset of ADHD suggests that formation of synapses and importantly the selection of synapses for removal in prefrontal cortex during childhood may contribute to the onset and lifelong pathophysiology. Those who are able to compensate for these prefrontal abnormalities by new synapse formation may be the ones who ‘’grew out of their ADHD’’ and this may explain why prevalence of ADHD in adults is only half that in children and adolescents .

5. KEY NEUROTRANSMITTERS IN ADHD AND THEIR AMINO ACID PRECURSOR Dopamine regulates attention, impulse control and pleasure- seeking. Norepinephrine plays a major role in attention and emotional/behavioral regulation.

6. PREVALENCE OF ADHD Prevalence of ADHD - 5% in Children and 2.5% in adults (APA 2013) INDIAN DATA: Prevalence of ADHD among primary school children was found to be 11.32%. Prevalence was found to be higher among the males, prevalence was found to be highest between the age group of 9 and 10 years. (Venkata et al, IJP 2013)

7. CLINICAL FEATURES Most cited characteristics of children with ADHD in order of frequency - hyperactivity, attention deficit, impulsivity, memory and thinking deficits, specific learning disabilities, speech and hearing deficits. Associated features - perceptual motor impairment, emotional lability and developmental coordination disorder. Significant percent - aggression and defiance . Overactivity usually the first symptom to remit while distractibility is the last . Hyperactivity - inappropriate excessive motor activity - restlessness, fidgeting and appearing to be driven by a motor. Behavior first noticed when the child is a toddler but can be normative before age 4.

8. Level of gross motor activity usually decreases with age however the inner sense of restlessness may continue into young adult life. Hyperactivity decreases when child is engaged in an activity they find particularly engrossing such as playing video games . Impulsivity - actions without forethought about consequences and may be associated with desire for immediate rewards or to avoid delay . Impulsivity - seen when the child engages in dangerous activities , yells out in class or interrupts or intrudes on others during games or conversations. Impulsive behavior might result in trouble with parents, teachers or other children including verbal or physical fights. .

9. Symptoms of impulsivity can persist into adulthood even after hyperactive symptoms have diminished Inattention - difficulty sustaining focus, trouble maintaining organization and being easily distracted by extraneous stimuli . Symptoms of inattention become prominent in elementary school when the child is approximately 8 to 9 years old and symptoms can be lifelong .

10. Diagnostic Criteria: Comparative ICD- 10 CRITERIA DSM- 5 CRITERIA Simultaneous hyperactivity, impulsivity and inattentiveness Symptoms can now occur by age 12 rather than by age 6 Symptoms prior to 6 years of age and of long duration. New descriptions were added to show what symptoms might look like at older ages Diagnosis of HKD may also be made in adult life using the same criteria, however, attention and activity must be judged with reference to developmentally appropriate norms. For adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children

11. COMORBIDITIES - 65 to 70% have one or more

12. Diagnosis Detailed medical history including family history and developmental history Rating scales should not be used independently, but can be particularly helpful in establishing the presence of core ADHD symptoms in more than one setting. ADHD- specific scales have been found to have greater than 90 percent sensitivity and specificity if used in the correct population. Commonly used rating scales: Conners Rating Scales for parents (CPRS- R) and teachers (CTRSR), Adolescent Self- Report Scale, Vanderbilt ADHD Diagnostic Parent and Teacher Scales Swanson, Nolan and Pelham (SNAPIV) Brown ADD Rating Scales for Children, Adolescents, and Adults

13. MANAGEMENT Pharmacologic treatment is considered the first line. Central nervous system stimulants are the first choice of agents. Shown to have the greatest efficacy with generally mild tolerable side effects. Stimulants are contraindicated in children, adolescents, and adults with known cardiac risks and abnormalities. Two group of stimulant medication that have achieved F.D.A approval are amphetamines and methylphenidates.

14. Methylphenidate Works by increasing norepinephrine and dopamine action action by blocking their reuptake. Enhancement in dorsolateral prefrontal cortex improves attention, concentration, executive function and wakefulness. In medically healthy youth, excellent safety records are documented for short and sustained- release preparations. Newer preparations - methylin , a chewable form of methylphenidate; daytrana , a methylphenidate patch; and dexmethylphenidate, the denantiomer (Focalin), and its longer acting form Focalin XR. Onset of action – 30 minutes Can take several weeks to attain maximum benefit. Usual dose range – 2.5 to 10 mg twice per day. Has habit abuse potential. Should be carefully tapered .

15. AMPHETAMINES Amphetamine is manufactured as immediate release formulation. Work by increasing norepinephrine and dopamine action by blocking their reuptake and facilitating their release. Enhancement in dorsolateral prefrontal cortex improves attention, concentration, executive function and wakefulness. Dosing – in ADHD for ages 6 years and older, initially 5 mg per day can increase by 5 mg each week , generally first dose is given on waking. Dose range – 5 to 40 mg per day . High habit forming potential Careful supervision is required during withdrawal from abusive use since severe depression may occur. Amphetamine works in patient not responding to other stimulants.

16. NONSTIMULANT MEDICATIONS Used for non responders or those who experience moderate to severe adverse events . Considered first line in individuals whose parents have a personal objection to stimulants or the child has comorbid anxiety symptoms or severe stimulant side effects. Atomoxetine and clonidine are the FDA approved non stimulant medications.

17. Atomoxetine Atomoxetine HCl (Strattera) is a norepinephrine uptake inhibitor approved by the FDA for children age 6 years and older. Mechanism of action is not well understood, but it is believed to involve selective inhibition of presynaptic norepinephrine transporter. Absorbed by the gastrointestinal tract, and maximal plasma levels are reached in 1 to 2 hours after ingestion. Shown to be effective for inattention as well as impulsivity . Half- life is approximately 5 hours and it is usually administered twice daily. Most common side effects - diminished appetite, abdominal discomfort, dizziness, and irritability. In some cases, increases in blood pressure and heart rate have been reported.

18. ALPHA- ADRENERGIC AGONISTS Clonidine and guanfacine should be tried in suboptimal response to psychostimulants, or in whom they cannot be tried. Can be used along with stimulants . Newer controlled- release formulations are better . Selective alpha (2A) adrenoceptor agonist, guanfacine extended- release is a once a day formulation that significantly improves the symptoms of inattention and hyperactivity- impulsivity in a dose range of 1- 4 mg/day.

19. Non Pharmacological Management DIET Minority of children might benefit from free fatty acid supplementation. Restriction of artificial food colourants (red and yellow) can also help a minority of children. Some parents who suspect their children’s behaviour is affected by the food they eat have observed improvement after elimination of certain foods after following a strict elimination diet.

20. PSYCHOEDUCATION Information regarding core symptoms, diagnostic criteria, etiology and empirically supported treatments (of ADHD, ODD, or CD ). What is and why the parent training Parent child coercive interaction cycle

21. Behavior Modification Behavior modification has been successfully applied to the classroom with a meta analysis of 70 studies showing an effect size of 0.6 SD compared to an attention control condition. In contrast, CBT has not shown to be effective . ADHD is a chronic condition for which ongoing long term monitoring and treatment is required to optimize functioning.

22. CONDUCT DISORDER

23. Disorder which involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social rules are violated .

24. ICD-10 DSM-V At least one symptom in last 6 months. Presence of at least 3/15 in the past 12 months from any of the categories , with at least 1 criterion present in the past 6 months Defiant provocative behaviour Four categories. 1.Agression to people and animals 2. Destruction of property 3.Deceitfullness or theft 4.Serious violation of rules Persistent severe disobedience

25. Aggression to People and Animals ICD-10 DSM-V Excessive levels of fighting or bullying Often bullies , threatens , or intimidates others. Often initiates physical fights . Has used a weapon Cruelty to animals or other people Has been physically cruel to people Has been physically cruel to animals .

26. Destruction of Property ICD-10 DSM-V Fire setting Deliberately engaged in fire setting . Severe destructiveness to property Has deliberately destroyed others’ property (other than by fire setting).

27. Deceitfulness or Theft ICD-10 DSM-V Has broken into someone else’s house , building, or car. Often lies to obtain goods or favors or to avoid obligations Stealing Has stolen items of nontrivial value

28. Serious Violations of Rules ICD-10 DSM-V Often stays out at night despite parental prohibitions, beginning before age 13 years. Running away from home Has run away from home overnight at least twice Truancy from school Is often truant from school, beginning before age 13 years

29. Etiology Individual level Genotypes - MAO-A promoter polymorphism Perinatal complications - Alcoholism in pregnancy Temperament - “callous” , “unemotional” Neurobiology- Volumetric changes in pre frontal cortex. Neuro transmitters- Low CSF serotonin levels is liked with aggression in children. Verbal deficits – increased deficits.

30. PRINCIPLES OF TREATEMENT Engage the family Select which treatment type to use and who should deliver it Develop strengths Treat comorbid conditions Promote social and scholastic learning

31. PSYCHOSOCIAL INTERVENTIONS Screening program can be used to predict lifetime disruptive behaviour . Adding problem solving skills in regular health curriculum.

32. Functional family therapy 8-12 one hour sessions are given in family home to ensure complete attendance. Age 11-18. 4 phases of treatment Engagement Motivation Behavioral change Generalization

33. CBT in conduct disorder Social skills training Kazdin’s problem-solving skills training (PSST) 12 week sequential program “Super solvers” Added with Parent Management Training Anger coping program 18 session intervention for school aged children

34. PHARMACOTHERAPY Stimulants – comorbid with ADHD Mood stabilizers- highly aggressive SSRI’S – target on symptoms of impulsivity, irritability, mood lability. Antipsychotics (RISPERIDONE)- Conduct disorder with normal IQ without ADHD.

35. OPPOSITIONAL DEFIANT DISORDER

36. Introduction Oppositional defiant disorder (ODD) is a psychiatric disorder that typically emerges in childhood, between ages 6 and 8, and can last throughout adulthood . Frequency and severity of ODD causes difficulty at home and at school. Children with ODD also struggle with learning problems related to their behavior . Two types of oppositional defiant disorder: Childhood-onset ODD: Present from an early age Requires early intervention and treatment to prevent it from progressing into a more serious conduct disorder Adolescent-onset ODD: Begins suddenly in the middle- and high-school years, causing conflict at home and in school

37. Symptoms Display behaviors that are challenging for parents and educators. Have difficulty interacting appropriately with peers and adults. Tend to be argumentative and defiant Common signs and symptoms(occur in multiple domains and not just at home)of ODD include: Being easily annoyed, Causing conflict Frequent temper tantrums Low tolerance for frustration, Lying  unprovoked anger Noncompliance with even simple requests Purposeful irritation of others Many children engage in oppositional behaviors with their parents but not in any other environment.

38. Diagnosis • Diagnosis of ODD requires a child to have at least four symptoms from the following categories. It must occur for min six months with negative impact on social/educational/ occupational functioning: Angry/irritable mood: Often loses their temper, Is often angry or resentful, Is often touchy or easily annoyed Argumentative/defiant behavior : Often argues with authority figures or adults, Actively defies or refuses to comply with requests from authority figures or with rules, Often deliberately annoys others, Often blames others for his or her mistakes Vindictiveness: -Has been spiteful or vindictive at least twice within the past six months

39. Causes Probably linked to a combination of biological, psychological, and social factors. Biological factors include: A parent with a history of attention-deficit/hyperactivity disorder (ADHD), ODD, or CD A parent with a mood disorder (such as depression or bipolar disorder) A parent with a substance use disorder Exposure to toxins Impairment in the part of the brain responsible for reasoning, judgment, and impulse control Poor nutrition A neglectful or absent parent A poor relationship with one or more parent

40. Social factors include:  Abuse, neglect, Chaotic environment Family instability (such as divorce or frequent moves ) Lack of supervision  Poverty Sometimes ODD occurs in conjunction with other behavior disorders or mental health issues, including Attention-deficit/hyperactive disorder (ADHD), Anxiety disorders, Depression, Bipolar disorder, and

41. Treatment Intervention must begins as early as possible with children with ODD and may develop into a conduct disorder . Treatment often involves the following: Cognitive problem-solving skills therapy: Children will learn to manage specific symptoms of ODD and to identify and solve problems that arise from living with ODD. Family therapy: Parents, siblings, and other family members may be invited to attend therapy with the child in order to improve family interactions and relationships. Parent training: Parents or caregivers may be taught behavior management strategies to reduce misbehavior in the home. Psychotherapy: Individual therapy can help a child learn new skills, such as anger management and impulse control. Social skills training: Formal social skills training can be effective in helping the child with ODD to interact with peers and adults

42. Pharmacological management While medication alone is not a recommended treatment for ODD but child may need medication to treat the symptoms of other coexisting conditions like ADHD, anxiety, and mood Training  Behavior modification methods. Better parenting techniques that can reduce misbehavior . Focus is on reinforcing pro-social behaviors . Form a Positive Relationship Engaging with the child in child-led play with the parent providing positive reinforcement and engagement. Set Expectations

43. Establish a Routine Having a routine can help children with ODD cope with activities at home Apply rules and follow routines consistently and fairly Discipline and Rewards Provide specific, labeled praise and rewards for the prosocial behaviors Verbal praise, Edible rewards, or items from a prize box. Social Interaction While interacting with others, ensure there is adequate supervision Work with peers for appropriate response to the ODD child's behaviors

44. Thankyou