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Adolescent Project

Impulse Control and Disruptive Behavior Disorders
June, 2003
Joe Ackerson, Ph.D. & Doug Bodin, M.S.
UAB Division of Pediatric Neurology

Our brains, and especially our frontal lobes, are perhaps the most defining aspect of being human. The frontal lobes, and the executive functions that depend upon them, help us to plan, organize, self-monitor and guide our behavior toward specific goals. There are a number of neurodevelopmental syndromes that involve inadequate development of one or more of the subcortical/frontal network. To adequately understand and treat individuals with these neurodevelopmental disorders we sometimes have to be willing to challenge many of our basic assumptions regarding motivation and volition. Primary care doctors, especially pediatricians, need to increase their familiarity with these disorders as they carry a significantly higher risk of substance abuse, unprotected premarital sex, academic drop-out and other risky behaviors. The following information is designed to help the pediatrician identify and initiate treatment for children and youth with disorders affecting impulse control and disruptive behavior.

1. Attention-Deficit/Hyperactivity Disorder (ADHD)

Entire textbooks, extensive media attention, and many parental concerns have been dedicated to this disorder, yet it remains somewhat controversial with regard to both diagnosis and treatment. It is beyond the scope of this purportedly brief article to comprehensively cover what is known and not yet known about ADHD and its treatment. Instead we will focus on some of the more practical and interesting aspects of ADHD and leave a more thorough coverage to Dr. Bill Pelham who will be presenting on this topic at the Alabama Chapter-AAP annual meeting in September.

With a prevalence rate of between 3 and 5 percent, ADHD is one of the most commonly diagnosed mental disorders in children and adolescents. Diagnostically, ADHD symptoms must be present prior to the age of seven. ADHD is characterized by symptoms from three categories: inattention, hyperactivity, and impulsivity. Combinations of symptoms across these three categories are reflected in three ADHD subtypes: predominately inattentive type, predominately hyperactive/impulsive type, and combined type. Symptoms of ADHD should be considered within a developmental context as many of these behaviors are considered developmentally appropriate at certain ages. It is when these symptoms are severe, persistent, and interfere with functioning that a diagnostic evaluation should be considered. Children with ADHD are at increased risk for developing Mood/Anxiety Disorders, Learning Disabilities, and other disruptive behavior disorders. ADHD by definition is established by ruling out alternative explanations, however, in every day practice it is often diagnosed based upon simple straightforward questionnaires and brief interviews that sometimes fail to consider alternative explanations as causative or at least contributory to the symptoms of concern. Too often, the diagnosis is made de facto by a teacher's observations and medications initiated without considering family factors, alternative psychiatric diagnosis and contributing school factors.

Signs of inattention and hyperactivity/impulsivity across developmental levels

Inattention:

Infancy
Early Childhood
Middle Childhood/ Adolescence
- brief gaze - distractible - miss instructions in school
- difficulty completing tasks - brief attention span - gives up easily on tasks
- distractible when eating - poor peer interactions - miss subtle social cues

Hyperactivity/Impulsivity/Impulsivity

Infancy
Early Childhood
Middle Childhood/ Adolescence
- squirming - runs into things - intrusive/interrupts others
- increased climbing - cannot sit still - trouble completing chores
- early motor development - frequent minor injuries - annoying behaviors

Interventions

Psychotherapy: Parent training in order to target disruptive behaviors is important. Also environmental strategies are helpful, such as imposing increased structure and minimizing distractions. Behavior modification strategies often help the child gain control over annoying aspects of their behavior and to master everyday routines through organizational and self-monitoring. Reward systems for desirable behavior are more effective than strictly punitive ones. Dr. Pelham has developed a very effective summer camp program that has operated for many years. Locally, Dr. Bart Hodgens ([email protected]), UAB Sparks Clinics will be establishing a similar program for the summer of 2004. There are an abundance of possibilities and resources on the Internet, including many that are nonscientific and misleading. We generally recommend the handout ADHD Resources Available on the Internet located at www.nichq.org/resources/toolkit/ and www.chadd.org.

Pharmacotherapy: Stimulant medications have been show to be effective in the majority of children and adolescents with ADHD and remain the "first line" choice of intervention. Medication treatment is difficult in some of these individuals due to side effects or tolerance. There are many new medications that have been developed for use in this population, including non-stimulant medications, which appear promising. It is also helpful to explain the four classes of medications most often used in treatment and to explain that the drugs within each class are not all the same (see Stimulant Management Chart located at www.nichq.org/resources/toolkit//). We generally recommend starting low, going slow, and being willing to increase to the maximally tolerated dose before switching to a different approach. It is also important to discuss alternative treatment strategies and their limitations. Parents often have the mistaken view that these approaches are safe and effective alternatives to mainstream medications. To date, none of these alternatives have received testing in randomized clinical trials that have demonstrated their efficacy in children with ADHD, although several are considered safe by the FDA such as valerian and lemon balm.

Physician counseling: Parents are bombarded with conflicting information about ADHD and its treatment. The widespread use of stimulants in the South has sparked heated discussions about whether more people are being appropriately recognized and treated or whether people are being overmedicated. A particularly powerful issue in these debates is the relationship between ADHD and substance abuse. Three questions often arise in discussions of this issue: (1) Are people with ADHD more like to develop substance abuse?; (2) Does using stimulant medication to treat ADHD lead to substance abuse?; and (3) Are the stimulant medicines themselves addictive?
The answer to the first question is well established by epidemiological studies and is clearly YES. Comorbidity of ADHD with bipolar or conduct disorder has a greater than additive effect on the risk of developing substance abuse. The second question, "Does using stimulant medication to treat ADHD lead to substance abuse?", is answered with a clear NO based on a recent meta-analytic review of 6 ADHD studies that revealed unmedicated subjects were about twice as likely as ADHD subjects treated with stimulant medications to develop substance abuse.
The answer to the third question, "Are the stimulant medicines themselves addictive?" is also NO, especially with the longer acting stimulants now available. One of the main advantages to the new generation of longer acting stimulants is that the methylphenidate is embedded in a thick paste that precludes IV use or snorting thereby giving the medicine little "street value." Also, once-a-day medicines administered in the morning before school are much less likely than medicines administered at school to be given away or sold to other students.


2. Tourette's Disorder

Tourette's Syndrome (TS) is a relatively rare disorder, occurring in approximately 4 or 5 individuals per 10,000. The disorder is characterized by the presence of impairing Tics, which are defined as sudden, rapid, recurrent, nonrhythmic stereotyped motor movements or vocalizations. These tics, which are exacerbated by stress, are experienced as being irresistible but can be suppressed for varying periods of time. Symptoms typically develop by age seven and decrease during adolescence and early adulthood. Tics typically begin as Eye Blinking then progress to include other parts of the face and head. Obsessive Compulsive symptoms as well as ADHD symptoms often co-occur with TS.

DSM-IV criteria - onset must be before the age of 18, the symptoms cause marked impairment in social, occupational, or adaptive functioning, and the symptoms are not the direct physiological effect of a substance (e.g., stimulants) or medical condition (e.g. Huntington's disease). Both multiple motor and vocal tics must have been present at some time during the course of the illness, although not necessarily at the same time. Tics occur many times a day, nearly every day for more than a year, with no tic-free period during this time lasting more than 3 consecutive months.

Common motor tics: Common vocal tics:
- eye blinking - throat clearing
- neck jerking - grunting
- facial grimacing - sniffing/snorting
- grooming behaviors - repeating words or phrases
- jumping - inappropriate words (coprolalia)
- smelling objects - repeating words heard (echolalia)


There is a high co-morbidity between TS and ADHD and Obsessive-Compulsive Disorder (OCD) so one should always query regarding the related disorders whenever TS is suspected. TS alone is associated with impulsivity and sometimes secondary emotional disorder due to the social harassment and isolation that can occur, especially if the tics are particularly disruptive. However, other neurocognitive impairments are typically not seen without the co-morbidity of ADHD or OCD. There is a high co-morbidity between TS and ADHD and Obsessive-Compulsive Disorder (OCD) so one should always query regarding the related disorders whenever TS is suspected. TS alone is associated with impulsivity and sometimes secondary emotional disorder due to the social harassment and isolation that can occur, especially if the tics are particularly disruptive. However, other neurocognitive impairments are typically not seen without the co-morbidity of ADHD or OCD.

Interventions

Psychotherapy: Numerous behavioral interventions have been investigated in the treatment of TS, including massed negative practice, assertiveness training, awareness training, cognitive therapy, relaxation therapy, and habit reversal training. Overall, studies have been unsuccessful at identifying positive effects from these treatment strategies, although there is some support for habit reversal training. Psychotherapy does play an important role in treating associated symptoms such as self-esteem and social skills.

Psychopharmacology: Research suggests that dopamine receptor drugs are the most effective in treating the tics associated with TS. There is some emerging evidence that atypical neuroleptics may be effective in suppressing tics. In some cases stimulants may "unmask" or exacerbate tics. However, overall medication approaches often prove less than satisfying and are generally withheld unless the tics prove to be socially disabling.

3. Conduct Disorder

One of the most commonly diagnosed conditions in outpatient and inpatient mental health facilities for children and adolescents with prevalence rates between 6 to 16 percent for boys and 2 to 9 percent for girls. The hallmark feature of Conduct Disorder is a repetitive and persistent pattern of behavior in which the basic rights of others and societal norms are violated. Early identification and treatment is crucial as age of onset is the number one risk factor for the development of adult Antisocial Personality Disorder. A large number of children with Conduct Disorder also meet criteria for ADHD and depression and anxiety are also common in this population. Adolescents with Conduct Disorder are at a higher risk for suicidal attempts and completion than those without the disorder. There are some neuropsychological and functional neuroimaging studies that suggest inefficient frontal or subcortical frontal neural substrate.

DSM-IV criteria- Three or more symptoms from the following four categories must be
present in the past 12 months, with at least one present in the past 6 months:

Aggression to people and animals (often bullies, threatens, or intimidates others; often initiates physical fights; has used a weapon that can harm others; has been physically cruel to people; has been physically cruel to animals; has stolen while confronting the victim; has forced someone into sexual activity).

Destruction of Property (has deliberately set fires with intention of causing damage or deliberately destroyed the property of others).

Deceitfulness or theft (has broken into someone else's house, building, or car; lies to obtain goods, favors, or avoid obligations).

Serious Violations of rules (often stays out at night despite parental prohibitions, prior to age 13; has run away from home overnight at least twice or once for lengthy period; is often truant from school, prior to age 13).

Two subtypes of Conduct disorder based on age of onset :

Childhood-onset:
     onset prior to age 10
Adolescent onset:
     onset after age 10
- usually male - lower male: female ratio
- frequent aggression towards others - less likely to display aggression
- disturbed peer relations - more normative peer relations
- more likely to persist into adulthood - likely to diminish after adolescence

Interventions:

Psychotherapy: Early identification and intervention is imperative. Parent training is often useful in developing a consistent behavior management plan between home and school. Individual counseling should focus on anger management and social contracts for the adolescent.

Psychopharmacology: Evidence based medication treatment for Conduct Disorder is limited and research suggests that psychopharmacological interventions should be used in conjunction with psychosocial treatments. Mood stabilizers, neuroleptics, and stimulants have been used to treat this disorder with varying to limited degrees of success.

4. Oppositional Defiant Disorder (ODD)

Prevalence rates range from 2 to 16 percent and the disorder is more common in families in which one parent has a history of mood disorder, ODD, CD, ADHD, Antisocial Personality Disorder, or Substance Related Disorder. The essential feature is a pattern of negativistic, hostile, and defiant behavior. ADHD, Learning Disabilities, and communication disorders are common in children and adolescents with ODD. Oppositional Defiant Disorder typically develops by age 8 with symptoms either diminishing as the child enters adolescence or evolve into Conduct Disorder.

DSM-IV Criteria- Four of the following are present for the same 6-month period, the
behaviors must cause impairment, and the behaviors are not better accounted for by a psychotic or mood disorder, and criteria are not met for Conduct Disorder.

- often loses temper
- often argues with adults
- often actively refuses to comply with adults' requests or rules
- often deliberately annoys people
- often blames others for his or her mistakes or misbehavior
- is often touchy of easily annoyed by others
- is often angry and resentful
- is often spiteful or vindictive

Signs of oppositional behaviors across developmental stages

Early Childhood
Middle Childhood
Adolescence
- extremely defiant - rebellious or argumentative - severe arguments
- frequently talks back - intentionally annoys others - no compromise
- tantrums - blames others for mistakes - substance use

Interventions:

Psychotherapy: Parent training is essential and is typically the most effective treatment, but depends upon early identification and treatment. Goals should focus on developing parenting skills to target specific behaviors. Social contracting will become important as the child enters adolescence.

Pharmacotherapy: Although a variety of medications are frequently used with this population, there are no proven medical treatments for defiant behaviors. Stimulant medications are often used to treat associated ADHD symptoms and other medications, such as mood stabilizers, are used to treat other associated symptoms.


Resource Materials
An excellent source for mental health resources within the pediatric setting is Bright Futures in Practice. Bright Futures was developed with funding through the U.S. Department of health and Human Services Health Resources and Service Administration (HRSA) Maternal and Child Health Bureau and the National Center for Education in Maternal and Child Health (NCEMCH) They have a mental health practice guide and toolkit. Their website address is www.brightfutures.org.

The American Psychological Association provides a wealth of consumer and practitioner oriented information, including useful hand-outs for a variety of mental health needs. Their consumer help center is particularly relevant and easy to access. Some pediatric oriented examples include Violence Prevention, Painful Shyness, and Coping and Resliency (in times of war or in response to disaster). Their website is www.apa.org.

The Alabama Psychological Association website provides information regarding licensed psychologists throughout Alabama. You can find your local provider by geographical location or by area of specialization (e.g., child psychology, neuropsychology, ADHD, etc.). Website address is www.alapsych.org.

An abundance of resources developed in part by the American Academy of Pediatrics is available at www.nichq.org.


Childhood Depression & Anxiety
May, 2003
Joe Ackerson, Ph.D. & Leon Dure, M.D.
UAB Division of Pediatric Neurology

Depression and anxiety in childhood and adolescence contribute to significant risky behaviors such as impaired decision-making, substance abuse, academic failure and drop-out, family dysfunction, and unprotected sex. The initial presentation of these problems is likely to be through the Pediatrician's office. However, given public misconceptions and biases against mental health issues, individuals and their parents are more likely to talk about their physical complaints than their psychological distress. This makes initial identification complicated. However, failure to appropriately identify the anxious or depressed youth can have serious adverse health outcomes including suicide, substance abuse, and inappropriate medical procedures. The following information is designed to help the primary care doctor appreciate, identify and initiate treatment for children and youth with depression and anxiety. Additional resource material is referenced at the end of this article.

1. Depression

Prevalence: from 2-5%. Affective disorders in children are often misdiagnosed, slow to remit, and often have detrimental effects on social and educational functioning. It is important to distinguish between symptom (depressed mood) and syndrome (mood, tearfulness, irritability, vegetative signs, and cognitive signs). Clinical depression represents a neurobiological abnormality with biopsychosocial etiology. Physical correlates may include brain wave patterns and altered presence of key neurotransmitters such as norepinephrine, serotonin, acetylcholine, dopamine, and gamma-aminobutyric acid.

DSM-IV criteria (most symptoms need to be present most of the time-- that is, daily) 5 or more of the following:

  • Depressed or irritable mood
  • Markedly diminished interest or pleasure in activities
  • Significant weight loss or gain-in children consider failure to make expected weight gains
  • Insomnia or hypersomnia
  • Psychomotor retardation or agitation
  • Fatigue, loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think or concentrate, or indecisiveness
  • Recurrent thoughts of death, suicidal ideation with or without a plan, or suicide attempt

Symptoms must cause significant distress or impairment in functioning, cannot be due to the direct physiological effect of substance (drugs, chemotherapy) or general medical condition (hypothyroidism, cancer) and cannot be better accounted for by Bereavement.

In children somatic complaints, irritability, and social withdrawal are common whereas psychomotor retardation, hypersomnia, and delusions are less common than in adults. In preschoolers you are more likely to see behavioral problems, irritability, withdrawal, apathy and developmental regression.

Onset develops over days to weeks, sometimes months. Depression is often accompanied by anxiety. Untreated depression typically lasts more than 6 months, though half (around 50%) recover on their own within 12 months. Usually (70%) fully remits with treatment, 5-10% will develop chronic depression, 20% will only have partial remission. 75% will have subsequent depressive episodes. It is commonly encountered as a co-morbid condition. Comorbid disorders often include anxiety and conduct disorders. Though unusual, it is possible to see mood congruent auditory hallucinations-typically single voice criticizing them. Depression can often lead to risky behaviors in adolescence.

Therapy
Psychotherapy: Cognitive behavioral therapy (CBT) very effective (65-75% remission), other forms of psychotherapy less impressive (typically around 30-40%).

Pharmacotherapy: Tricyclic antidepressants ((TCAs) have been studied the most, with response rate ranges from 56% to 70%. Serotonin Re-uptake Inhibitors (SRIs) have yielded 66%-81% positive response rate. Unfortunately 40% relapse after 2 years. Start low, go slow, if signs of mania develop stop and switch to mood stabilizer. If no effect after 4 weeks on adequate dose switch to different agent.

2. Anxiety Disorders

A group of related disorders (prevalence rates range from 2-12%) with the most common in childhood being: social phobias, Separation Anxiety Disorder, generalized anxiety disorder, somatization (including conversion disorder), PTSD, and Obsessive Compulsive Disorder. Defined as a marked and persistent fear beyond what the situation should elicit. Anxiety in children often is expressed in terms of physical complaints. It is important to distinguish between social impairments due to anxiety versus those seen as part of a pervasive developmental disorder (e.g., autism) and between the types of problematic behaviors that reflects parenting issues or impulse control disorder (e.g., ADHD) and those seen as part of a childhood anxiety disorder. Persistent medical complaints can be the hallmark of an anxiety disorder. Finally, certain anxiety disorders, such as nonepileptic (a.k.a. pseudo) seizures or other conversion reactions can mimic medical conditions.

DSM-IV criteria for Generalized Anxiety Disorder

  • Excessive Anxiety and Worry (more days than not for 6 months)
  • Child has difficulty controlling the worry
  • One of the following: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance
  • Symptoms are not due to the direct physiological effects of a substance (drugs, chemotherapy) or a general medical condition (hypothyroidism, cancer) and do not occur exclusively during a course of Depression, a Psychotic Disorder, or a Pervasive Developmental Disorder.

Common Pediatric signs of Anxiety

Developmental regression
Crying, tantrums
Over or under attachment
Inhibited interactions (sometimes to point of mutism)
Social Withdrawal
School refusal

Typical Stress Reactions in Children:

5 and under: 6-12 years: Adolescence:
1) behavior problems 1) nightmares 1) drop in grades
2) tantrums 2) drop in grades 2) withdrawal
3) irritability 3) aggression 3) less time with friends
4) whining 4) bedwetting 4) poor appetite
5) fussy 5) hyperactivity 5) sleep problems
6) clingy 6) poor appetite 6) exaggerate fears
7) repetitive behaviors 7) sleep problems 7) focus on one fear
8) intolerance for change    


Treatment
Psychotherapy: Cognitive behavioral therapy (flooding, systematic desensitization, modeling, contingency management) is often effective (63-70% no longer meeting diagnostic criteria after treatment).

Pharmacotherapy: Although few medications have been FDA approved for treatment of anxiety in children younger than 12, SRI therapy has been shown to be effective in reducing anxiety symptoms in children with social phobia, separation anxiety disorder, and generalized anxiety disorder.

For conversion or other somatoform disorders (anxiety disorders that present with primary physical symptoms) appropriate providing accurate information that the cause and treatment of the disorder involves psychological processes is critical, as is avoiding unnecessary medical procedures.

Resource Materials
An excellent source for mental health resources within the pediatric setting is Bright Futures in Practice. Bright Futures was developed with funding through the U.S. Department of Health and Human Services Health Resources and Service Administration (HRSA) Maternal and Child Health Bureau and the National Center for Education in Maternal and Child Health (NCEMCH). They have a mental health practice guide and toolkit. Their website address is www.brightfutures.org.

The American Psychological Association provides a wealth of consumer and practitioner oriented information, including useful hand-outs for a variety of mental health needs. Their consumer help center is particularly relevant and easy to access. Some pediatric oriented examples include Violence Prevention, Painful Shyness, and Coping and Resliency (in times of war or in response to disaster). Their website is www.apa.org.

The Alabama Psychological Association website provides information regarding licensed psychologists throughout Alabama. You can find your local provider by geographical location or by area of specialization (e.g., child psychology, neuropsychology, ADHD, etc.). Website address is www.alapsych.org.