Page 1203 - TNFlipTest

Toronto Notes 2019 Disruptive, Impulse Control, and Conduct Disorder
Features
• difficulttodifferentiatefromhighlyvariablenormativebehaviourbeforeage4,butoftenidentified upon school entry
• ruleoutdevelopmentaldelay,sensoryimpairments,geneticsyndromes,encephalopathiesortoxins (alcohol, lead)
• increasedriskofsubstanceabuse,depression,anxiety,academicfailure,poorsocialskills,comorbidCD and/or ODD, adult ASPD
• associatedwithfamilyhistoryofADHD,difficulttemperamentalcharacteristics
Treatment
• non-pharmacological:parentmanagement,angercontrolstrategies,positivereinforcement,socialskills training, individual/family therapy, behaviour therapy, tutors, classroom intervention, exercise routines, extracurricular activities, omega-3 fatty acids
• pharmacological:1stlinestimulants(methylphenidate,amphetamines);2ndlineatomoxetine;3rdline/ adjunct nonstimulants (guanfacine, clonidine, buproprion)
• for comorbid symptoms: antidepressants, antipsychotics
Prognosis
• 70-80%continueintoadolescence,buthyperactivesymptomsusuallyabate
• 65%continueintoadulthood;secondarypersonalitydisordersandcompensatoryanxietydisordersare
identifiable
Disruptive, Impulse Control, and Conduct Disorder
Oppositional Defiant Disorder
• prevalence:2-16%,M=Fafterpuberty
Diagnosis
• patternofnegativistic/hostileanddefiantbehaviourfor≥6mowith≥4of:
■ angry/irritable mood: easily loses temper, touchy or easily annoyed, often angry and resentful
■ argumentative/defiant: argues with adults/authority figure, defies requests/rules, deliberately annoys,
blames others for their own mistakes or misbehaviour
■ vindictiveness: spiteful or vindictive twice in past 6 mo
■ difference between normal and ODD is frequency of behaviours (most days if age <5 yrs, weekly if
age ≥5 yrs) while considering developmental level, gender, culture
■ behaviour causes significant distress or impairment in social, academic, or occupational functioning
■ behaviours do not occur exclusively during the course of a psychotic, substance use, or mood
disorder
■ diagnosis of DMDD supersedes ODD if criteria for both are met
• impactofODD:poorschoolperformance,fewfriends,strainedparent/childrelationships,riskof developing mood disorders later on
Treatment
• parent:parentmanagementtraining,psychoeducationandfamilytherapytoreducepunitiveparenting and parent-child conflict
• behaviouraltherapy:toteach,practice,andreinforceprosocialbehaviour
• social:school/day-careinterventions
• pharmacotherapyforcomorbiddisorders
Conduct Disorder
• prevalence:1.5-3.4%(M:F=4-12:1)
Etiology
• parental/familialfactors:parentalpsychopathology(e.g.ASPD,substanceabuse),child-rearing practices (e.g. child abuse, discipline), low socioeconomic status (SES), family violence
• childfactors:difficulttemperament,ODD,learningproblems,neurobiology
Diagnosis
• differential:ADHD,depression,headinjury,substanceabuse
• diagnosis:usemultiplesources(AchenbachChildBehaviouralChecklist,Teacher’sReportForm)
■ pattern of behaviour that violates rights of others and age appropriate social norms with ≥3 criteria noted in past 12 mo and ≥1 in past 6 mo
■ aggression to people and animals: bullying, initiating physical fights, use of weapons, forced sex, cruel to people and/or animals, stealing while confronting a person (e.g. armed robbery)
■ destruction of property: arson, deliberately destroying others’ property
■ deceitfulness or theft: breaking and entering, conning others, stealing nontrivial items without
Psychiatry PS39
A Systematic Review and Analysis of Long-Term Outcomes in Attention Deficit Hyperactivity Disorder: Effects of Treatment and Non-Treatment BMC Med 2012;10:99
Purpose: To determine the long-term outcomes of ADHD and whether there is an effect on long-term outcomes with treatment.
Methods: Systematic review of studies,
including patients with diagnosed or symptomatic presentation of ADHD, assigned to pharmacological, non-pharmacological or multi-modal treatments
or to a no-treatment control. Outcome measures included use/addictive behaviour, academic outcomes, antisocial behaviour, social function, occupation, self-esteem, driving outcomes, services use, and obesity.
Results: Untreated participants with ADHD had poorer outcomes vs. non-ADHD participants in 74% (n=244) of studies, while 26% (n=89) showed similar outcomes. 72% (n=37) of studies showed a benefit from ADHD treatment vs. untreated ADHD and 28% (n=15) showed no benefit. Treatment of ADHD was found to be beneficial in studies looking at driving (100%), obesity (100%), self-esteem (90%), social function (83%), academic outcomes (71%), drug use/addictive behaviour (67%), antisocial behaviour (50%), and occupation (33%). Conclusion: Overall, people with ADHD have poorer long-term outcomes than controls (those without ADHD). For those with ADHD, treatment improves long-term outcomes.
ODD kids “ARE BRATS” Annoying
Resentful
Easily annoyed
Blames others Rule breaker Argues with adults Temper Spiteful/vindictive
confrontation