Disruptive Behavioral Disorders in Children: Introduction
We expect our children to be active and energetic, but when they exceed the norms for their age in their displays of activity, their lack of impulse control, or their inability to focus attention, they are likely to experience problems in social, familial, academic, and emotional interactions. Self-esteem is adversely affected, and these individuals are at greater risk of developing antisocial disorders, substance abuse disorders, academic failure, employment failure, and secondary mood and anxiety disorders. These behavioral variants, therefore, cause a significant social burden and are often brought to the attention of primary care physicians. This chapter addresses three Axis I childhood behavioral problems likely to be encountered in the primary care setting: attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD).
The controversies surrounding behavioral problems and their treatments have generated several comprehensive reviews that have improved understanding of these conditions. In 1998, the American Medical Association Council on Scientific Affairs concluded that there was little evidence of overtreatment with neurostimulants in the United States. That same year, the National Institutes of Health (NIH) conducted a Consensus Conference on the Diagnosis and Treatment of ADHD that concluded “there is validity in the diagnosis of ADHD as a disorder with broadly accepted symptoms and behavioral characteristics that define the disorder.” Details are available at http://proxy.library.upenn.edu:9643/concensus/cons/110/110_statement.htm. An International Consensus Letter from prominent leaders in the field in 2002 concluded decisively that “All the major medical associations and government health agencies recognize ADHD as a genuine disorder because of the scientific evidence indicating it is so overwhelming.”
Attention-Deficit/Hyperactivity Disorder
- A persistent pattern of inattention, hyperactivity, or both; more frequent and severe displays of impulsivity.
- Academic underachievement and behavioral problems.
Up to 20% of school-aged children in the United States have behavioral problems and at least half of these involve attention of hyperactivity difficulties. ADHD is the most common and well-studied of the childhood behavioral disorders. All family physicians have encountered the classically hyperactive child and his or her beleaguered parents and teachers in practice and in social interactions, but, likewise, may have overlooked the quiet but inattentive “daydreamer.” The seeming dichotomy between the hyperactive and the inattentive types of ADHD can be confusing to both clinicians and the public. Primary care physicians should be familiar with the features of this disorder and are ideally positioned to evaluate and treat the majority of children and families dealing with this condition.
Neurophysiologic data suggest that there is no single cognitive or behavioral deficit common to all individuals with ADHD. Emerging data suggest that individuals with ADHD have abnormalities in the frontal-striatal circuits but the exact problem has not been isolated.
Individuals diagnosed with ADHD are likely to experience significant difficulties with executive functioning which impairs academic performance, social relationships, self-control, and memory. Thomas Brown, Ph. D. outlines six executive functions observed in individuals diagnosed with ADHD. These include (1) organizing and prioritizing (difficulty getting started on tasks); (2) focusing and sustaining attention (easily distracted); (3) regulating alertness, sustaining effort (drowsiness); (4) managing frustration (low frustration tolerance or disproportionate emotional reactions); (5) working memory (difficulty retrieving information); and (6) self-regulation (difficulty inhibiting verbal and behavior responses.
There is good evidence that ADHD is not caused by too much television (although patients may be attracted and distracted by it); by food allergies (although the rare child may display inattention secondary to such allergies); by excess sugar, artificial flavorings, colorings, or preservatives in food; by poor home life or parenting skills (although the behaviors of ADHD do upset the classic parent-child confrontation seen in ODD and account for some of that common comorbidity); or by poor schools or teachers. Some data suggest that maternal smoking, cocaine use, and alcohol use in pregnancy could play a role in some children with ADHD. Fetal alcohol syndrome results in similar problems with hyperactivity, inattention, and impulsivity.
Evidence now favors ADHD as a lifelong process. Preschoolers are being identified with great predictability for developing ADHD symptoms once in school. Up to 80% of ADHD children have features into adolescence and 65% into adulthood. The family physician is ideally placed to assist patients across the life span.
Analysis by the Centers for Disease Control and Prevention (CDC) of data from the 2003 National Survey of Children’s Health places the national prevalence of ADHD in the Unites States among children aged 4-17 years at 7.8% (11% of males and 4.4% of females) and shows that 4.3% of children are currently being treated with medications (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a2.htm). The ratio of male to female children is estimated at 4:1 for the hyperactive type of ADHD and 2:1 for the inattentive type. For ADHD alone, without comorbid factors such as CD, there are no differences along socioeconomic classes. Among races in the United States, the CDC reports the following prevalences: 8.6% of white children, 7.7% of black children, 9.7% of multiracial children, and 4.5 % of others. It would seem that ADHD arises across ethnic groups and, although cultural and ethnic factors may contribute to variations in diagnosis, there is no cultural or ethnic component to the etiology and true prevalence of ADHD.
Studies support a substantial genetic contribution to ADHD. Sibling studies show a risk of ADHD among siblings of a child with the diagnosis that is two to three times that in normal controls. The parents of children with ADHD have a higher incidence of the condition than societal norms and have a higher incidence of other psychiatric problems, and relatives have a higher incidence of mood problems, anxiety disorders, learning disabilities, CD, antisocial personality disorder, substance abuse problems, depression, and marital dysfunction.
There is no single diagnostic test or tool for ADHD. The diagnostic criteria included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (DSM-IV-TR) are the current basis for the identification of individuals with ADHD. Meeting these criteria (Table 8-1) does not exclude the possibility of other conditions, and the full differential diagnosis must be considered by the evaluating physician (see Table 8-2). There is rarely a need for extensive laboratory analysis, but screening for iron deficiency and thyroid dysfunction is reasonable.
| A. Either (1) or (2): |
| (1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: |
| Inattention |
| (a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities |
| (b) Often has difficulty sustaining attention in tasks or play activities |
| (c) Often does not seem to listen when spoken to directly |
| (d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) |
| (e) Often has difficulty organizing tasks and activities |
| (f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) |
| (g) Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools) |
| (h) Is often forgetful in daily activities |
| (2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: |
| Hyperactivity |
| (a) Often fidgets with hands or feet and squirms in seat |
| (b) Leaves seat in classroom or in other situation in which remaining seated is expected |
| (c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) |
| (d) Often has difficulty playing or engaging in leisure activities quietly |
| (e) Is often “on the go” or often acts as if “driven by a motor” |
| (f) Often talks excessively |
| Impulsivity |
| (g) Often blurts our answers before questions have been completed |
| (h) Often has difficulty awaiting turn |
| (i) Often interrupts or intrudes on others (eg, butts into conversations or games) |
| B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. |
| C. Some impairment from the symptoms is present in two or more setting (eg, at school [or work] and at home). |
| D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. |
| E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). |
| Code Based on Type: |
| 314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both criterion A1 and A2 are met for the past 6 months. |
| 314.00 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Type: if criterion A1 is met but criterion A2 is not met for the past 6 months. |
| 314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if criterion A2 is met but criterion A1 is not met for the past 6 months. |
| Coding Note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “In Partial Remission” should be specified. |
| 314.9 Attention-Deficit/Hyperactivity Disorder: Not Otherwise Specified: this category is for disorders with prominent symptoms of inattention or hyperactivity/impulsivity that do not meet criteria for attention-deficit/hyperactivity disorder. Examples include |
| 1. Individuals whose symptoms and impairment meet the criteria for attention-deficit/hyperactivity disorder, predominantly inattentive type but whose age at onset is 7 years or older. |
| 2. Individuals with clinically significant impairment who present with inattention and whose symptom pattern does not meet the full criteria for the disorder but have a behavioral pattern marked by sluggishness, daydreaming, and hypoactivity. |
| General Medical Conditions | Neurologic Conditions | Psychiatric Conditions | Environmental Conditions |
|---|---|---|---|
| Hearing impairment | Learning disabilitya | Conduct disordera | Improper learning environment (eg, unsafe, disruptive)a |
| Visual impairment | Tic disorders (eg, | Oppositional defiant disorder | Mismatch of school curriculum with child’s ability (eg, gifted, learning disabled) |
| Medication effects, (eg, antihistamine decongestants, β-agonists, anticonvulsants | Tourette syndrome | Substance abuse | Family dysfunction or stressful home environmenta |
| Asthma | Seizure disorders | Anxietya | Poor parenting (eg, inappropriate, inconsistent, punitive)a |
| Allergic rhinitis | Mental retardation (eg, fetal alcohol syndrome, fragile X syndrome, phenylketonuria) | Post-traumatic stress disorder | Child neglect or abusea |
| Eczema | Developmental delays | Depression | Parental psychopathology |
| Enuresisa | Brain injury | ||
| Encopresis | Sleep disorders | ||
| Malnutrition | |||
| Hypothyroidism | |||
| Lead toxicity |
The American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics (AAP), with input from members of the American Academy of Family Physicians, have formulated evidence-based practice guidelines to aid in the improvement of current diagnostic and treatment practices. These guidelines can be accessed at the AAP’s Web site (). The diagnosis is made by parent interview, direct observation, and use of standardized and scored behavioral checklists such as the Connors Parent and Teacher Rating Scales, Child Behavior Checklist (CBCL), Vanderbilt ADHD Diagnostic Parent and Teacher Scales, Achenbach, along with computerized tests (Gordon Diagnostic Testing, Connors Continuous Performance Task, TOUA) measuring impulsivity and inattention that are specific for ADHD and should include input from both parents and teachers. The criterion for diagnosis on the checklist is two standard deviations above the mean in the number of ADHD symptoms displayed.
Three subtypes of ADHD are recognized (see Table 8-1): predominantly inattentive (accounting for 20%-30% of ADHD individuals), predominantly hyperactive-impulsive (accounting for <15%), and the combined subtype (the most common, accounting for 50%-75% of cases). Individuals with the inattentive subtype have fewer behavioral problems but are subject to mood fluctuations. Those with an inattentive component have more academic problems than those with a purely hyperactive component. Individuals with the combined subtype have the highest incidence of comorbid psychiatric problems and problems with substance abuse, and are the most impaired.
Some children may not fully meet DSM-IV-TR criteria. A useful reference for these children has been supplied by the AAP in its Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. The DSM-PC considers environmental and developmental influences on the more common variations in behavior to help in the diagnosis and management of children with attention, hyperactivity, and impulsivity.
ADHD is often associated with other Axis I diagnoses, especially in patients referred to psychiatrists. From 35% to 60% of referred ADHD children have ODD, and 25%-50% will develop CD. Of these, 15%-25% progress to antisocial personality disorder in adulthood. Indeed, ADHD can be used as a reliable early predictor of disruptive behavior disorders. A family history of conduct problem aids this prediction. Among children with ADHD, those who are most hyperactive-impulsive are at greatest risk for development of ODD; however, it is possible to distinguish between the two disorders. ODD behaviors, such as “loses temper,” “actively defies,” and “swears,” are less characteristic of children with ADHD.
Anxiety disorders are more common in the predominantly inattentive type of ADHD; for example, 25%-40% of referred children have a concurrent anxiety disorder. As many as 50% of referred children with ADHD eventually develop a mood disorder—most commonly depression, diagnosed in adolescence. The diagnosis of bipolar disease in childhood increased the risk of concurrent label of ADHD because of the overlap of behaviors. About half the children with Tourette syndrome have ADHD, and the symptoms of ADHD usually precede the other symptoms of that syndrome. The medical treatment of Tourette syndrome and ADHD is complicated by the effects of stimulant medications on tics. Determination of the coexistence of ADHD and Tourette syndrome is vital to ensure that appropriate social and educational services are obtained for these children. (Tourette syndrome is discussed in detail in Chapter 43.)
There appears to be a strong correlation between sleep disorders and ADHD. Children who snore are almost twice as likely as their nonsnoring counterparts to meet diagnostic criteria for ADHD. This is particularly true for younger (<8 years) boys, for whom the risk is three times higher in snorers. Whether this is a cause-and-effect phenomenon needs further study, but this link should be kept in mind when taking a history.
There is a definite association among ADHD, academic problems, and learning disabilities. Between 20% and 50% of children with ADHD have at least one type of learning disorder. In any child with ADHD in whom academic achievement seems to lag behind intelligence, testing for learning disabilities should be performed. The documentation of a learning disability makes it easier to obtain academic accommodations and modifications through individual educational plans as protected by the Individuals with Disabilities Education Act (IDEA). Individuals with ADHD have a higher risk of reading problems, as well as arithmetic and writing difficulties. They are often poor spellers and have poor penmanship. These problems are associated with difficulties in the executive functions of integration of working memory and motor coordination and fluency, all mediated by the lack of intact inhibitory processes.
There does not seem to be an association between intelligence and ADHD, although the verbal scores, mental arithmetic scores, and digital span scores in many intelligence quotient (IQ) tests can be lower in children with ADHD due to problems with working memory. These differences appear when hyperactive behavior is factored out of the testing and are thought to be due to the methodology rather than true differences in intelligence. The true impact of ADHD is on the application of intelligence in everyday functioning and academic work.
Medications commonly used in the treatment of ADHD are listed in Tables 8-3 and 8-4.
| Generic Class/Brand Name | Dose Form | Typical Starting Dose | FDA Max/Day | Off-Label Max/Day | Comments |
|---|---|---|---|---|---|
| Amphetamine preparations | |||||
| Short-acting | |||||
| Adderall | 5,7.5,10,12.5,15,20,30 mg tab | 3-5 y: 2.5 mg qd | 40 mg | >>50 kg: 60 mg | Short-acting stimulants often used as initial treatment in small children (<16 kg), but have disadvantage of bid-tid dosing to control symptoms throughout day. |
| Dexedrine | 5 mg cap | 3-5 y: 2.5 mg qd | |||
| Dextrostat | 5, 10 mg cap | ≥6 y: 5 mg qd-bid | |||
| Long-acting | |||||
| Dexedrine spansule | 5, 10, 15 mg cap | ≥6 y: 5-10 mg qd-bid | 40 mg | >>50 kg:60 mg | Longer-acting stimulants offer greater convenience, confidentiality, and compliance with single daily dosing, but may have greater problematic effects on evening appetite and sleep. |
| Adderall XR | 5, 10, 15, 20, 35, 30 mg cap | ≥6 y: 10 mg qd | 30 mg | >50 kg: 60 mg | |
| Lisdexamfetamine | 30, 50, 70 mg cap | 30 mg qd | 70 mg | Not yet known | |
| Methylphenidate preparations | |||||
| Short-acting | |||||
| Focalin | 2.5, 5, 10 mg cap | 2.5 mg bid | 20 mg | 50 mg | Short-acting stimulants often used as initial treatment in small children (<16 kg), but have disadvantage of bid-tid dosing to control symptoms throughout day. |
| Methylina | |||||
| Ritalina | 5, 10, 20 mg tab | 5 mg bid | 60 mg | >50 kg:100 mg | |
| Intermediate-acting | |||||
| Metadate ER | 10, 20 mg cap | 10 mg qAM | 60 mg | >50 kg: 100 mg | Longer-acting stimulants offer greater convenience, confidentiality, and compliance with single daily dosing, but may have greater problematic effects on evening appetite and sleep. Metadate CD and Ritalin LA caps may be opened and sprinkled on soft food. |
| Methylin ER | 10, 20 mg cap | 10 mg qAM | 60 mg | >50 kg: 100 mg | |
| Ritalin SRa | 20 mg | 10 mg qAM | 60 mg | >50 kg: 100 mg | |
| Metadate CD | 10, 20, 30, 40, 50, 60 mg | 20 mg qAM | 60 mg | >50 kg: 100 mg | |
| Ritalin LA | 10, 20, 30, 40 mg | 20 mg qAM | 60 mg | >50 kg: 100 mg | |
| Long-acting | |||||
| Concerta | 18, 27,36, 54 mg cap | 18 mg qAM. | 72 mg | 108 mg | Swallow whole with liquids. |
| Daytrana patch | 10, 15, 20, 30 mg patches | Begin with 10 mg patch qd, then titrate up by patch strength | 30 mg | Not yet known | Nonabsorbable tablet shell may be seen in stool. |
| Focalin XR | 5, 10, 15, 20 mg cap | 5 mg qAM | 30 mg | 50 mg | |
| Selective norepinephrine reuptake inhibitors | |||||
| Atomoxetine | |||||
| Straterra | 10, 18, 25, 40, 60, 80, 100 mg cap | Children and adolescents <70 kg: 0.5 mg/kg/d for 4 d; then 1 mg/kg/d for 4 d; then 1.2 mg/kg/d | Lesser of 1.4 mg/kg or 100 mg | Lesser of 1.8 mg/kg or 100 mg | Not a Schedule II medication. Consider if active substance abuse or severe side effects of stimulants (ie, mood lability, tics); give qAM or divided doses bid (effects on late evening behavior); do not open capsule; monitor closely for suicidal thinking and behavior, clinical worsening, or unusual changes in behavior. |
| Generic Class/ Brand Name | Dose Form | Typical Starting Dose | Max/Day | Comments |
|---|---|---|---|---|
| Antidepressants | ||||
| Buproprion | 75, 100 mg tab | Lesser of 3 mg/kg/d or 150 mg/d >150 mg | Lesser of 6 mg/kg or 300 mg with no single dose | Lowers seizure threshold; contraindicated if current seizure disorder |
| Wellbutrina | 100, 150, 200 mg tab | |||
| Wellbutrin SR | 150, 300 mg tab | |||
| Wellbutrin XL | Usually given in divided doses, bid for children, tid for adolescents, for both safety and effectiveness | |||
| Imipramine | ||||
| Tofranila | 10, 25, 50, 75 mg tab | 1 mg/kg/d | Lesser of 4 mg/kg/d or 200 mg | Obtain baseline ECG before starting imipramine and nortriptyline |
| Nortriptyline | ||||
| Pamelora | 10, 25, 50, 75 mg tab | 0.5mg/kg/d | Lesser of 2 mg/kg/d or 100 mg | |
| Aventila | ||||
| α2-Adrenergic agonists | ||||
| Clonidine | 0.1, 0.2, 0.3 mg tab | <45 kg: 0.5 mg qhs.; titrate in 0.05-mg increments bid, tid, qid; >45 kg: 0.1 mg qhs., titrate in 0.1-mg increments bid., tid, qid | 27-40.5 kg: 0.2 mg; 40.5-45 kg: 0.3 mg | May be used alone or as adjuvant to another medication for ADHD |
| Catapresa | >45 kg: 0.4 mg | Effective for impulsivity and hyperactivity; modulating mood level; tics worsening from stimulants; sleep disturbances | ||
| Guanfacine | ||||
| Tenexa | 1, 2 mg tab | <45 kg: 0.5 mg qhs; titrate in 0.5-mg increments bid, tid, qid; >45 kg: 1 mg qhs, titrate in 1-mg increments bid, tid, qid | 27-40.5 kg: 2 mg 40.5-45 kg: 3 mg >45 kg: 4 mg | May not see effects for 4-6 wk Review personal and family cardiovascular history Taper off to avoid rebound hypertension |
The efficacy of this class has been proven in controlling some of the manifestations of ADHD but they are not a “cure.” The fact that stimulants are controlled substances (Schedule II) with an abuse potential justifies the close scrutiny of their use. About 65% of children with ADHD show improvement in the core symptoms of hyperactivity, inattention, and impulsivity with their first trial of a stimulant and up to 95% will respond when given appropriate trials of various stimulants. The management of these medications can be complex, and treatment failures may more often be the result of improper treatment strategies than effective medication.
The pharmacokinetics of stimulants are characterized by rapid absorption, low plasma protein binding, and rapid extracellular metabolism. Up to 80% may be excreted in the urine unchanged or de-esterized. Therefore half-lives are short and frequent dosing or sustained release preparations are necessary. Response does not seem to be weight dependent so weight dependent dosing strategies are not as helpful as with other medications. Plasma levels of these agents have not been shown to be useful in determining optimal dosing.
Successful management of the stimulants used in ADHD treatment requires a systematic approach such as that outlined in the following model. It comprises four phases: (1) counseling, (2) titration, (3) maintenance, and (4) potential termination.
The goals of this phase are to explain the rationale for the trial of the medication with both the expected positive effects and potential negative effects. Children must understand why they are being treated. They should know that the physician and not their parents or teachers is responsible for their treatment. The details of the treatment should also be discussed, including the choice of medication, dosage, and expected frequency of follow-up. Parents should be told which behaviors to monitor, what side effects to expect, and how they will be dealt with. Physicians should also explain the expected changes in dosing and timing of the medications, and the anticipated eventual shift from short-acting to sustained-release preparations.
An important step is to determine the targeted symptoms, which will be unique for each child and family. This requires that the physician and parents review the child’s symptoms and prioritize them based on their effect on the child’s performance. Responders have shown specific effects, as outlined below.
Motor Effects
- Reduced hyperactivity
- Decreased excessive talking and disruption
- Improved handwriting
- Improved fine motor control
Social Effects
- Reduction in off-task behaviors
- Improved ability to play and work independently
- Decreased intensity of behavior
- Reduced anger
- Improved (but not normalized) peer social interaction
- Improved parent-child interactions
- Reduced verbal and physical aggression
Cognitive Effects
- Greater sustained attention
- Reduced distractibility
- Improved short-term memory
- Increased accuracy of academic work
Perhaps the most important step at this phase is the choice of medications. Stimulants most commonly used include methylphenidate (Ritalin), dexmethylphenidate (Focalin), dextroamphetamine (Dexedrine), and mixed amphetamine salts (Adderall). Pemoline (Cylert), used in the past was discontinued in the United States in October 2005 because of liver toxicity. It requires biweekly monitoring of liver enzymes and the signing of an informed consent. In recent years, novel drug delivery systems have been developed for stimulants and these formulations have become routine in clinical practice. These agents range from short-acting immediate release formulations to extended release formulations in the form of pills, pellets, a prodrug, a patch or transdermal system and an osmotic release pump system. The benefits of a medication may be apparent for as short as 2-4 hours or as long as 15 hours depending on the formulation employed. Concerta is a form of methylphenidate that uses an osmotic pump mechanism to provide effective extended treatment approximating the three times daily dosing of methylphenidate immediate release. Daytrana is a methylphenidate transdermal delivery system (MTS). Patches are applied once daily and deliver a consistent amount of methylphenidate during the time the patch is worn. The MTS system may be a useful option for patients who have difficulty swallowing or tolerating oral formulations or for those who need flexible duration of medication effect.
Vyvanse (lisdexamfetamine dimesylate) is an innovative dextroamphetamine prodrug. This system may be associated with diminished abuse potential and toxicity potential.
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