Behavioural Problems – CADDRA 2011

ADHD

  • 5-12% school-aged children; M:F = 4:1; average onset 3 yo
    • girls tend to have inattentive/distractible symptoms
    • Boys have impulsive/hyperactive symptoms
    • Identify upon school entry
  • Etiology: genetic – family hx of ADHD, cognitive – difficult temperamental characteristics, arousal
  • co-occurring conditions complicates the clinical presentation & need to be dealt with
    • 50-90% ADHD children ≥1 & ~50% ≥ 2 comorbid conditions
    • 85% ADHD adult  ≥1 a comorbid condition
  • Prognosis: 65% coninue into adulthood, secondary personality d/o & compensatory anxiety d/o are identifiable
  • hyperactive symptoms usually abate
  • ATENTION features
    1. ANNOYING
    2. TEMPERAMENTAL
    3. ENERGETIC
    4. NOISY
    5. TASK INCOMPLETION
    6. INATTENTIVE
    7. OPPOSITIONAL
    8. NEGATIVISM

 Dx – 3 subtypes (DSM4)

  1. Combined type: ≥ 6 inattention & hyperactivity-impulsivity symptoms
  2. Inattention Type: ≥ 6 inattention symptoms:
    1. careless mistakes, fails to complete tasks
    2. disorganized, distractible, forgetful
    3. Loses things necessary for tasks or activities
    4. Doesn’t listen when spoken to directly
    5. Can’t sustain attention in tasks or play
    6. Avoids / dislikes tasks that require sustained mental effort
  3. Hyperactive-Impulsive Type: ≥ 6 hyperactivity-impulsivity symptoms
    • Hyperactivity
      1. Fidgets, squirms in seats, leaves seat when expected to remain seated
      2. Runs and climbs excessively, can’t play quietly
      3. On the “go”, driven by a motor
      4. Talks excessively
    • Impulsivity
      1. Blurts out answers before questions completed
      2. Difficult awaiting turns
      3. Interrupts/intrudes on others
  • Symptoms persiste >6mo and Onset < 7 yo
  • Interferes with academic, family, social functioning: symptoms present in ≥ 2 settings (home, school, work)
  • Doesn’t occur exclusively during the course of another psychiatric disorder

 1 Because behavioural problems in children are often multifactorial, maintain a broad differential diagnosis and assess all factors when concern has been raised about a child’s behaviour:

– look for medical conditions (e.g., hearing impairment, depression, other psychiatric diagnoses, other medical problems).
– look for psychosocial factors (e.g., abuse, substance use, family chaos, peer issues, parental expectations).
– recognize when the cause is not attention deficit disorder (ADD) (e.g., learning disorders, autism spectrum disorder, conduct disorder).

Rule out:

  1. Learning disorders, developmental delay, hearing/visual defects,
  2. hx of head injury, encephalopathies
  3. thyroid issues, congenital problems (fetal alcohol syndrome, fragile x)
  4. toxins: Lead poisoning, alcohol
  5. traumatic life events (abuse)
  6. Risk of substance abuse: cannabis, cocaine
  7. Risk of depression, anxiety, academic failure, poor social skills, CD/ODD, ASPD

Common differentials with symptoms or Signs not Characteristic of ADHD

Psychiatric Disorders
  1. Generalized Anxiety Disorder: Worry for >6mo that the person cannot control; lack of energy; anxious and somatic anxiety symptoms.
  2. Obsessive Compulsive Disorder: + obsessions or compulsions that interfere with level of function.
  3. Major Depression: Episodic decline in mood or depressed mood and/or dysphoria; suicide-related issues; low energy; psychomotor retardation.
  4. Bipolar Disorder I or II (manic or hypomanic episode): Episodic change from baseline; psychotic symptoms; grandiosity; pressured speech; recent decreased need for sleep.
  5. Psychotic Disorder (schizophrenia or schizoaffective disorder): Psychotic symptoms.
  6. Autism Spectrum Disorder: Qualitative impairment in social interactions, communication or odd eccentric behaviours.
  7. Oppositional Defiant Disorder: Defiant; loses temper; annoys others and is easily annoyed; spiteful or vindictive.
  8. Conduct Disorder: Presence of conduct disorder criteria e.g. aggression to people and animals; destruction of property; deceitfulness or theft; serious violations of rules.
  9. Disruptive Mood Dysregulation Disorder: Severe recurrent disproportional temper outbursts (verbal ± physical) ≥3x /wk in ≥2 settings for ≥ 12 months. Dx first made between 6-10 yo.
  10. Substance Use Disorder: U tox screen confirms presence of substance.
  11. Learning or Language Disorder : Consultation with psychologist or neuropsychologist confirms presence of the disorder.
  12. Tic Disorder/Tourette syndrome (TS): Presence of vocal or motor tics (or both for TS).
  13. Borderline Personality Disorder: Abandonment anxiety; hourly mood fluctuations; suicidal threats; identity disturbance; dissociative symptoms or micro psychotic episodes; feelings of emptiness.
  14. Antisocial Personality Disorder: Lack of remorse; lack of responsibility; lack of empathy.
  15. IQ-related problems: Intellectual disabilities or Gifted child: Cognitive assessment confirms diagnosis
    • Note: If IQ is within the normal range: explore whether curriculum is not well matched to child’s ability
Medication-related
  • Medication with cognitive dulling side effect (e.g. mood stabilizers) or psychomotor activation (e.g. decongestants, beta agonist)
General Medical Conditions – Investigations confirm the diagnosis of the medical condition
  1. Head Trauma/Concussion: Since underlying ADHD can increase risk for head trauma, it is important to look for timing of cognitive symptoms apparition (present before, or appeared or worsened after head trauma).
  2. Seizure Disorders: Neurology assessment confirms diagnosis.
  3. Hearing or Vision Impairment: Audiology and vision evaluation confirms diagnosis.
  4. Thyroid Dysfunction: TSH levels indicate hypothyroidism or hyperthyroidism
  5. Hypoglycemia Abnormally: low glucose blood levels confirms diagnosis
  6. Severe Anemia: CBC and anemia investigations confirm diagnosis
  7. Lead Poisoning: Lead blood level measurement confirms diagnosis
  8. Sleep Disorders: Sleep lab assessment confirms diagnosis
  9. Fragile X Syndrome: Molecular genetic testing for FMR-1 gene / genotype confirms diagnosis.
  10. Fetal Alcohol Spectrum Disorder (FASD)
    – Possible presence of intellectual disability
    – Growth deficiency and FAS facial features
    – Evaluate prenatal alcohol exposure risk
    – Magnetic brain imaging
    – Psychological assessment (including intellectual, language processing, and sensorimotor)
  11. Phenylketonuria: Blood test confirms diagnosis
  12. Neurofibromatosis: Café au lait spots
Environmental Factors
  1. Unsafe or disruptive learning environment
  2. Family dysfunction or poor parenting
  3. Child abuse or neglect
  4. Attachment Disorder

 2 When obtaining a history about behavioural problems in a child:
– ask the child about her or his perception of the situation.
– use multiple sources of information (e.g., school, daycare).

Simple questions to ask (any one should trigger concern). With an adult, clarify if the symptoms have been present since they were young.
1. Do you find it harder to focus, organize yourself, manage time and complete paperwork than most people?
2. Do you get into trouble for doing impulsive things you wish you had not?
3. Do you find you are always on the go, or that you are constantly restless or looking for something exciting to do?
4. Do you find it really difficult to get motivated by boring things, though it is easier to do the things you enjoy?
5. Do people complain that you are annoying or are easily annoyed, unreliable or difficult to deal with?

Make sure you review the patient’s strengths NOT just his or her areas of weakness. This establishes a rapport with a child, adolescent or adult and their family

It is recommended that physicians complete an assessment form (A), a screener (S) and at least one rating scale (R). For children, the CADDRA Teacher Assessment Form (T) is also suggested; for adults, a collateral rating scale is useful.

  • Weiss Symptom Record (WSR) (S) for parents, teachers and adolescents in high school
  • Weiss Functional Impairment Rating Scale for Parents (WFIRS-P) (R)
  • CADDRA Teacher Assessment Form (T) to be completed by the teacher who knows the patient best
  • SNAP-IV-26 (R)

With adolescents, first ask whether their friends use drugs or alcohol. A positive response suggests they are likely a high risk candidate. Where substance abuse exists, there continues to be controversy about the timing of ADHD pharmacological treatment.


3 When treating behavioural problems in children for whom medication is indicated, do not limit treatment to medication; address other dimensions (e.g., do not just use amphetamines to treat ADD, but add social skills teaching, time management, etc.).

Non-Pharmacological Tx
  • Family: Parent management, Positive reinforcement, Individual / family therapy
  • Social: Anger control strategies, Social skills training
  • School: Resource room, tutors, classroom intervention, exercise routines, extracurricular activities
Pharmaco Tx:
  • Stimulants: methylphenidates: Ritalin, Concerta (long-acting), Biphentin
  • Amphetamines: dextroamphetamine, mixed amphetamine salts (Adderall), Vyvanse
  • SNRI: atomoxetine (Strattera)
  • Comorbid symptoms: antidepressants, antipsychotics

4 In assessing behavioural problems in adolescents, use a systematic, structured approach to make an appropriate diagnosis:
– specifically look for substance abuse, peer issues, and other stressors.
– look for medical problems (bipolar disorder, schizophrenia).
– do not say the problem is ‘‘just adolescence.’’

Comorbid problems

  1. Mood Disorders
    • Major Depression
      • Treat the most impairing disorder first.
      • Moderate to severe depression should be treated first and suicide must be assessed in all cases.
      • Dysthymia and mild depression may benefit from ADHD treatment first.
      • Stimulants can be combined with the majority of antidepressants when monitored. Also consider CBT.
      • In adults, Bupropion and Desipramine may reduce ADHD symptoms, but with an effect size significantly lower than psychostimulants.
    • Bipolar Disorder
      1. Treat Bipolar Disorder first. Treatment of ADHD can be offered when Bipolar Disorder is stabilized. Refer to specialist.
  2. Anxiety Disorders
    • GAD, Panic Disorder, Social Phobia, OCD, PTSD
      • Treat the most impairing disorder first. Some patients may show worsending of anxiety and some may show improvement in their symptoms. ADHD treatments can be less tolerated in some individuals in this population. Note possible pharmacological interactions with meds metabolized through CYT2D6 system.
      • Start low, go slow but titrate up to therapeutic dose. If not tolerated, switch to another medication, like atomoxetine.
      • Also consider CBT. If Atomoxetine is much less effective, can refer to specialist for augmentation with stimulants.
  3. Autism Spectrum Disorder (ASD)
    • ADHD treatments can be less tolerated in some individuals in this population but could be very helpful in the general management. Start low, go slow, but titrate up to therapeutic dose. If not tolerated, switch to another medication. Refer to specialist for specific interventions for ASD
  4. Psychotic Disorders
    • Treat Psychotic Disorder first. (Refer to a specialist: treatment of ADHD can trigger a psychotic relapse in a predisposed patient). Stable patients who are in remission may benefit from ADHD treatment.
  5. Oppositional Disorder and Conduct Disorder
    • Treat both conditions. Oppositional Disorder needs psychosocial interventions. Moderate and severe cases might require combinations of psychostimulants and an Alpha 2 agonist such as clonidine, or guanfacine.
    • Conduct Disorder needs psychosocial interventions and may involve legal issues. Pharmacological treatment of ADHD may help better modulate reactive-impulsive behaviours. Adding an antipsychotic might improve the symptoms of conduct disorder, according to some cases cited in the literature.
  6. Borderline Personality Disorder
    • Reducing impulsivity and increasing attention when treating comorbid ADHD may help the patient with a personality disorder to better participate in their psychological treatments.
  7. Antisocial Personality Disorder
    • Treating patients with APD + ADHD requires more complex and comprehensive interventions. Medical Problems Clinical aspects to take into account in the treatment process when comorbid with ADHD
  8. Epilepsy
    • Treat epilepsy first, then ADHD. New onset seizure should be managed with antiepileptic medication. Level of antiepileptic medications may increase with methylphenidate due to enzyme inhibition.
  9. Tics
    • ADHD medications do not cause tics but some may increase or reduce tics. However, the presence of tics is not a contraindication for ADHD medication. Atomoxetine, clonidine and guanfacine have shown promise in this population. Addition of antipsychotic may be required in severe cases.
  10. Sleep-related Disorders
    • Treat primary disorder first. Psychostimulants can reduce residual sleepiness and improve daily function in sleep apnea and narcolepsy with or without ADHD.
  11. Sleep Apnea
    • Cardiovascular problems Physical exam before treatment (BP, pulse and cardiac auscultation). EKG and cardiac consult if positive cardiac history or structural heart disease. Measure BP and pulse and monitor vital signs and cardiac side effects during treatment.
  12. Obesity
    • Discuss healthy eating and sleep habits and increase exercise. ADHD treatment may improve patient’s capacity to implement lifestyle changes
  13. Learning disorders
    • Treat specific learning disorders. ADHD treatments can improve attention, allowing improvement in learning skills. School adaptations, study and academic organizational skills should be considered and offered when needed.
  14. Speech Disorders
    • Treat specific speech disorders. Refer to special education teacher, psychologist and/or speech and language therapist for specific interventions.
  15. Developmental Coordination Disorder
    • Treat coordination disorders. Refer to occupational therapist and/or physiotherapist for specific interventions.
  16. Low IQ . High IQ
    • Treat ADHD and adapt non pharmacological approaches to the patient’s IQ level.
    • Treat ADHD and adapt curriculum to child’s IQ level.

5 In elderly patients known to have dementia, do not attribute behavioural problems to dementia without assessing for other possible factors (e.g., medication side effects or interactions, treatable medical conditions such as sepsis or depression).


References:

 

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Posted in 10 Behavioural Problems, 99 Priority Topics, FM 99 priority topics, Psych

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