Lesson 8
EXTERNALIZING DISORDERS
(ADHD, OPPOSITIONAL DEFIANT
DISORDER, CONDUCT DISORDER)
Elif Akçay
Chid and Adolescent Psychiatrist
Ankara Bilkent City Hospital
2023-2024 ASBU 1
Undergraduate Program in Psychology
• Differentiate and diagnose
– Mild or marked ADHD
– Other related mental/physical health problems
• Treat or manage through:
– Psycho-education
– Basic psycho-social interventions
– Pharmacotherapy
• Know when to refer patient to a specialist
• Inattention, hyperactivity and
impulsivity
• Two Diagnoses:
– ADHD (DSM)
– Hyperkinetic Disorder (ICD)
• Affects 6 % of children
• Abnormal neuro-psychological
functioning and neurobiological
correlates
Tree climbing
(Vauvau, 2009)
1800’s Heinrich Hoffman
“Impulsive Insanity”
&
“Defective Inhibition”
Der Struwwelpeter, an illustrated book
portraying children misbehaving
(“Impulsive Insanity/Defective
Inhibition”) by Heinrich Hoffman (1854).
• 1902 Lancet article
• 1920’s “minimal brain damage”
• 1930’s “hyperkinetische
Erkrankung”
• 1960’s “minimal brain
dysfunction”
• 1937 Benzedrine discovered
• Hyperkinetic Syndrome of
Childhood” in ICD-9
• 1980 inattention recognized
• DSM-III Attention-Deficit Disorder
with or without Hyperactivity
• Tell us about your cases
• Do you recognize ADHD?
• Are there any other points to discuss?
ADHD:
• Is common
• Can be serious
• Can persist
• Is stigmatizing
• Is treatable
• Core symptoms
– Inattention, hyperactivity, impulsivity
– Present in more than one context
– Leading to functional impairment
• Subtypes Russell Barkley
https://www.youtube.co
– In DSM: combined, predominantly m/watch?v=GR1IZJXc6d8
&feature=related
hyperactive, predominantly inattentive
– In ICD: Hyperkinetic disorder
ADHD
Epidemiology
• Prevalence (Polanczyk et al, 2007)
– 6% for children
– 3% for adolescents
• Male>Female
• ADHD (DSM definition) > HKS (ICD definition)
ADHD
Differences According to Age
• Pre-school: play < 3mins, not listening, no sense of danger
• Primary school: activities < 10 mins, forgetful, distracted,
restless, intrusive, disruptive
• Adolescence: attention< 30 mins, no focus/planning,
fidgety, reckless
• Adult: incomplete details, restless, forgetful, impatient,
accidents
ADHD
Course
• Some chronic
• Unclear persistence (Faraone 2006)
– 15% full persistence
– 40-60% partial remission
• Severe cases more persistent
ADHD
Associations with Durability of Symptoms
• Lower academic achievement
• Marital problems and dissatisfaction
• Divorce
• Difficulties dealing with offspring
• Lower job performance
• Unemployment
• Employment below potential
• Traffic accidents
• Other psychiatric disorders
ADHD
Etiology & Risk Factors
• Strong genetic component (76%)
• Perinatal factors – some evidence
• Neurobiological deficits – growing evidence
• Deprivation and family factors – important for
course and outcome
• Discuss:
– popular explanations in your cultural context?
ADHD
Neurobiology
• Frontal-striatal
dysfunction
– mediated by GABA
– modulated by
catecholamines
• Catecholaminergic
dysregulation
• Delay in cortical
maturation
• Defiant, aggressive antisocial behaviors
• Problems with social relationships
• IQ tends to be lower than in the general
population
• Specific learning problems
• Co-ordination problems
• Specific developmental delay
• Poor emotional self-regulation
https://www.youtube.com/watch?v=4r3XWj269_g&ab_channel=King%2
7sCollegeLondon
https://www.youtube.com/watch?v=5_rASNOzUcE&ab_channel=JMR
ey%27sIACAPAPTextbook
• Information from at least two contexts
– Teachers are key!!!
• Medical and psychiatric assessment
• Assess co-morbidity
***No additional tests necessary
• Only for research use!!!
• The majority of neuropsychological tests are
copyrighted and expensive, which restricts their use,
although specific tests can be of help.
• Intelligence tests (e.g., Wechsler) can be useful in
clarifying intellectual deficits or IQ level and its
implications.
• The Continuous Performance Test (CPT-II), Wisconsin
Cart- Sorting test, STROOP test, and “Go/no go” tests
are useful for research.
• The stroop test is used to measure
attention. It takes advantage of our
ability to read words more quickly
and automatically than naming
colors. The cognitive mechanism
involved in this task is called directed
attention: one has to manage one’s
attention, inhibit or stop one
response in order to say or do
something else. It is one of the tests
that, despite not being diagnostic,
provides data about attentional
ability.
• Situational hyperactivity
• Behavioral disorders (ODD/CD)
• Emotional disorders
• Tics, chorea or other dyskinesias
• Misuse of substances
• Autism Spectrum Disorder
• Intellectual Disability
*Frequent Comorbidity*
• Parental mental health issues
• Severe marital discord or recent divorce
• Domestic violence
• Child abuse or neglect
• Severe bullying or exclusion by peers
• Severe deprivation or poverty
• SNAP IV: http://www.adhd.net/snap-iv-form.pdf
• SDQ : http://www.sdqinfo.org
• Many other proprietary (not free) scales
ADHD
Review of Assessment Algorithm
• Does the child have problems
with inattention and over-
activity?
Consider ADHD if the answer to
• Are symptoms persistent,
both is ‘yes’
severe and causing
impairment in the child’s
functioning?
Explore ways to address
environmental stressor
• Explore the impact of as part of management
environmental stressors (e.g.,
plan
family)
Manage or refer
• Rule out medical or other
conditions 25
• Individually tailored
• Reduce symptoms
• Improve educational outcomes
• Reduce family and school-based problems
ADHD
What works?
Evidence Based Treatments:
• Best evidence for stimulant medication
• Behaviour treatments also effective in mild to moderate cases
• Psycho-education for parents and school
• The decision to use non-pharmacological versus pharmacological
intervention should be based on;
– patient’s age,
– profile of symptoms and disease severity,
– individual risk for side effects,
– treatment adherence issues,
– comorbid disorders,
– parents’ and child’s preference,
– cost, access to medication, and availability of trained therapists.
27
• Generally effective, but smaller effect size than
medication
• Behavior therapy
– Individual, not always generalize
– Parent management training: particularly useful in
younger children and for associated behavior problems
– School based: child in front of class, short tasks etc.
• First line treatment in younger children or milder
cases
Methylphenidate or Amphetamines
– Efficacy and safety well established
– ES 0.8-1.1; clinical response in 70%
– Dose: titrate for optimum response
– Short/long acting (sustained release) available
– NOT on WHO list of essential medicines
• Common side effects: nausea, weight loss, insomnia,
agitation
• More serious side effects: tics, psychotic symptoms,
raised blood pressure, growth retardation
• Atomoxetine
• Clonidine
– Start dose 0.1 mg at bedtime
– Add a.m. dose after 3-7 days, then midday dose after 3-7
days
– Increments by 0.05-0.1mg, max. 0.4mg
• Imipramine
– 2-3 times/day; 1-4mg/kg/day
– 30-50% response rate in 10 studies
– ECG recommended prior to treatment (cardiotoxicity)
*Non-stimulants: less effective, more side effects, try only
when stimulants not available, not tolerated or not appropriate*
• If no response and severe impairment after
pharmacological treatment combined with
behavioral approaches
– Re-evaluate diagnosis and co-morbidity
– Check for undetected social adversity or abuse
• If still no response after 6 months consult with
specialist
• AACAP ADHD Resource Center
http://www.aacap.org/AACAP/Families_and_Youth/Resource
Centers/ADHD_Resource_Center/Home.aspx
• NICE Guideline, Tools,
and Resources
http://www.nice.org.uk/guidance/cg72/resources
• The Basics
• Diagnosis
• Epidemiology
• Aetiology & risk factors
• Assessment
• Treatment
• “A persistent pattern of defiant, disobedient,
and antagonistic behavior toward adults”
• No antisocial or aggressive acts like the ones
found in conduct disorder
• Common
• Substantial impairment
• Poorer adjustment outcomes
• Increased cost to society
• DSM-5: 4 or more of the following, not just with
siblings, lasting greater than 6 months
1. Often loses temper
2. Often touchy or easily annoyed
3. Often angry and resentful
4. Often argumentative with adults/authority figures
5. Often defies or doesn’t follow rules
6. Often deliberately annoys others
7. Often blames others
8. Spiteful or vindictive 2 x in 6 months
• ICD-10: persistent pattern of provocative, hostile and
non-compliant behavior, with low temper threshold
• Prevalence: 2-10%
• Boys>girls
• Symptoms decline after age 10
• Rarely diagnosed in older children
• Estimates vary across countries
• Majority do not develop conduct disorder
• High rates of comorbidities
• Genetics
• Gene-environment interplay
• Earlier age of onset of antisocial symptoms
• Different temperamental routes
• Rejection by non-deviant peers
• Callous and unemotional traits
• Social and economic disadvantage
• Neighborhood violence
• Negative parenting
• “Coercive family processes”
• Gather information from multiple sources
• Assess comorbidities
• Consider family, school and neighborhood
• Watch for bullying or peer deviance
• Assess for learning difficulties
• Phobias
• Other anxiety disorders
• Obsessive Compulsive Disorder
• ADHD
• Autism
• Depression
• Identify and treat comorbidities
• Address modifiable risks
• Parent management training (see Chapter A.12)
– The Incredible Years
– Triple P (Positive Parenting Program)
• Alternative approaches
• School-based interventions
• Individual therapy (anger management)
• Medication
Parents:
• Improve positive parenting skills
• Enhance problem solving, conflict resolution, communication skills
Child:
• Develop effective communication, problem-solving and anger
management skills
Family:
• Family counseling and support
Classroom:
• Social skills sessions from teacher or counselor
• No evidence for medication in ODD alone
• Stimulants improve conduct and oppositional
symptoms in ADHD
• Sodium valproate may help with aggression in
hospitalized children with ADHD if stimulants failed
• No effects on severe irritability with Lithium
• Evidence lacking for use of SSRI’s for anger in children
• Anti-manic agents should not be given for ODD only
• Dopamine antagonists: use short-term on a case by
case basis
• ICD-10 has a category for conduct disorders, F91. The clinical
descriptions
and diagnostic guidelines state:
“Examples of the behaviours on which the diagnosis is based
include the following: excessive levels of fighting or bullying;
cruelty to animals or other people; severe destructiveness to
property; firesetting; stealing; repeated lying; truancy from school
and running away from home; unusually frequent and severe
temper tantrums; defiant provocative behaviour; and persistent
severe disobedience. Any one of these categories, if marked, is
sufficient for the diagnosis, but isolated dissocial acts are not.”
• Between 2% and 8% of children and adolescents
have conduct disorders.
• The sex ratio is approximately 4 to10 males for each
female overall, with males further exceeding
females in the frequency and severity of behaviours.
• ICD-10 has a category for conduct disorders, F91. The clinical
descriptions
and diagnostic guidelines state:
“Examples of the behaviours on which the diagnosis is based
include the following: excessive levels of fighting or bullying;
cruelty to animals or other people; severe destructiveness to
property; firesetting; stealing; repeated lying; truancy from school
and running away from home; unusually frequent and severe
temper tantrums; defiant provocative behaviour; and persistent
severe disobedience. Any one of these categories, if marked, is
sufficient for the diagnosis, but isolated dissocial acts are not.”
• Psychosocial therapy for ODD and CD is crucial, as no medications have
been FDA approved specifically for these conditions.
• A licensed psychologist or therapist is generally involved, and family
members have a role in therapy.
• Parental training, parent-child interaction therapy, individual and family
therapy, social-skills training, cognitive problem-solving training, and
cognitive-behavioral therapy have proven benefits in ODD or CD.
• Psychosocial therapy for CD generally involves psychotherapy, which
enables the child to control anger and express it in more socially
acceptable ways. A more specific branch of psychosocial therapy, known
as cognitive-behavioral therapy, can position the child’s thinking to be
cognitive and reason-based.
• Cognitive-behavioral therapy may incorporate impulse-control and anger-
management skills.
• At present, there are no pharmacological interventions approved
specifically for conduct disorder.
• Pharmacotherapy is used adjunctively in the management of both
CD and ODD.
• Since both of these disruptive disorders usually coexist with
conditions such as ADHD and major depressive disorder, medication
management of comorbidities is first-line treatment.
• ODD and CD may be comorbid in more than 50% of ADHD cases.
• In addition, 14% of children with ODD or CD have comorbid anxiety
disorder and 9% have comorbid depression.
• Therefore, it is imperative to manage the coexisting condition.
Stimulants, nonstimulants, antipsychotics, mood stabilizers, and
antidepressants have been used off-label for CD and ODD.
