Attention-Deficit Hyperactivity Disorder and the Disruptive Behavior Disorders

1. List and describe the major characteristics of attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder is defined as a persistent pattern of poor attention span, hyperactivity/impulsivity, or both, that is developmentally inappropriate, causes clinically significant impairment across settings, and present early in development. Under DSM-IV-TR, diagnosis is as follows:

Combined Type
6 or more criteria from inattention construct plus 6 or more criteria from hyperactivity/impulsivity construct
Predominantly Inattentive Type
6 or more criteria from inattentive construct
Predominantly Hyperactive/Impulsive Type
6 or more criteria from hyperactivity/impulsivity construct
Not Otherwise Specified
Meets some criteria from either inattentive or hyperactivity/impulsivity constructs, but less than 6 within either construct

The inattention construct contains 9 criteria, as follows:

(1) Fails to give close attention to details
(2) Often has difficulty sustaining attention
(3) Often does not seem to listen when spoken to
(4) Often does not follow through/fails to finish
(5) Often has difficulty organizing tasks and activities
(6) Often avoids tasks that required sustained mental effort
(7) Often loses things
(8) Is often easily distracted
(9) Is often forgetful

The hyperactivity/impulsivity construct includes 6 hyperactivity and 3 impulsivity criteria:

(1) Often fidgets with hands or feet or squirms
(2) Often leaves seat
(3) Often runs about or climbs excessively
(4) Often has difficulties playing or engaging in leisure activities quietly
(5) Is often “on the go” or “driven by a motor”
(6) Often talks excessively

(7) Often blurts out answers
(8) Often has difficulty awaiting turn
(9) Often interrupts

2. Discuss general issues related to epidemiology and etiology of ADHD.

Prevalence of ADHD in school-age children is about 5-7% but does not take into account the preschool, adolescent, and adult population. Boys have higher incidence compared to girls (3-5:1) because females usually don’t have such obvious symptoms. Age of onset is usually by age 3 but diagnosis is often delayed until the child is in school.

The etiology of ADHD is unknown but it is suspected to be a condition resulting from brain damage. Current hypothesis include family genetic factors (since ADHD is highly heritable), prenatal toxic exposure, prematurity, and prenatal insult to fetal nervous system. These factors may contribute to alteration of functioning of the prefrontal cortex.

Psychosocial factors are thought not to play a primary role though some environmental etiological factors have been proposed: toxins, such as lead, various food additives, sugar intoxication, need for vitamins and nutrients, etc. However, non of these factors have been substantiated with empirical support.

3. Describe the presentation of pre-school aged children, elementary school aged children, adolescents, and adults with ADHD.

Pre-School Child with ADHD
(1) Temper tantrums
(2) Argumentative behavior
(3) Aggressive behavior
(4) Fearless behavior
(5) Accidental injury
(6) Non-compliance
(7) Sleep disturbance

Elementary-School Child with ADHD
(1) Difficulty with work requiring cognitive effort
(2) Difficulty in peer relationships
(3) Non-compliant behavior

Adolescents with ADHD
(1) Internal sense of restlessness (rather than gross motor activity)
(2) Poor organized approaches to school and work
(3) Poor follow-through on tasks
(4) Failure to complete independent academic work
(5) Risky behaviors

Adults with ADHD
(1) Chronic disorganization
(2) Requires written lists and other reminders of activities (that often get lost)
(3) Not finishing projects
(4) Moving from one activity to another

A lower number of symptoms should be considered as indicative of ADHD diagnosis in the adolescent and possibly adult age range. ADHD is a lifelong disorder that can be mediated by medications, but never cured.

4. Discuss general issues related to the treatment of ADHD.

Medications are empirically proven for treating ADHD and include CNS stimulants, antidepressants, and neurobiofeedback.

In milder cases or in cases when medications are not wanted, contraindicated, or not effective, parental training and behavior management is used. Parental training and behavior management are used to modify the environment of the child, producing a prosthetic environment.

Expectations of treatment by parents and therapist should be made clear and kept consistent. Reinforcement and consequences of child’s behavior should be frequent, consistent and contingent. It is important to understand the concept of the child’s limited time horizon where future planning is not performed beyond a certain point in the future and does not affect current behavior. Individual psychotherapy, addressing self-control issues, social skills and related issues, anger management, etc. may be used adjunctively.

5. List and describe the major characteristics of conduct disorder and oppositional-defiant disorder.

Oppositional-defiant (ODD) and conduct disorders (CD) are disruptive behavior disorders. Disruptive behavior disorder NOS is a grab-bag when neither criteria for ODD or CD are filled.

Oppositional-defiant disorder is characterized by a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months. Symptoms must cause significant impairment, not occur exclusively during the course of a psychotic or mood disorder, and do not meet criteria for conduct disorder. Diagnosis with ODD must fill 4 or more criteria, as follows:

Oppositional-Defiant Disorder
(1) Loses temper
(2) Argues with adults
(3) Defies rules
(4) Deliberately annoys people
(5) Blames others for his or her misbehavior
(6) Touchy or easily annoyed
(7) Angry and resentful
(8) Spiteful or vindictive

Conduct disorder is a repetitive and persistent pattern of behavior in which the basic rights of others social norms and rules are violated. Symptoms must cause significant impairment. At least 3 criteria must be met within the past 12 months with at least 1 criteria presenting within the last 6 months. Child-onset type of conduct disorder rare and is defined as the onset of at least one criterion characteristic before age 10. Adolescent-onset type is more frequent with absence of any criteria characteristic prior to age 10.

Conduct Disorder
Aggression to People and Animals:
(1) Bullies, threatens, or intimidates
(2) Physical fights
(3) Used a weapon
(4) Physically cruel to people
(5) Physically cruel to animals
(6) Stolen while confronting a victim
(7) Forced sexual activity

Destruction of Property:
(8) Fire setting
(9) Destroyed others property

Deceitfulness or Theft:
(10) Broken into other’s house, building, or car
(11) Lies to obtain goods or favors (i.e., cons others)
(12) Stole items of non-trivial value without confronting victim

Serious Violation of Rules:
(13) Stays out at night despite parental prohibitions
(14) Ran away at least twice
(15) Often absent from school

6. Discuss general issues related to etiology and developmental psychopathology of disruptive behavior disorders.

Etiologic factors include child temperament and parenting skills. “Difficult” child temperament may mean that the child’s behavior is not socially rewarding to the parent, resulting in less positive and more negative child-parent interactions, and causing the child to become even more difficult. Alternatively, poor parenting skills can result in “difficult” child behaviors, causing parent to respond with abuse, and overly punitive approaches and making the child even more difficult.

The Patterson social learning, interaction-based model emphasizes family socialization processes and suggests a coercion hypothesis in which both parent and child can’t get what they want unless through coercion of aggression of each other, resulting in a relationship based on coercion. Patterson says that children with ODD or CD exhibit fewer positive behaviors, more violent disciplinary techniques, more criticism, more permissiveness, less monitoring of child’s behavior, more reinforcement of inappropriate behaviors, and ignoring/punishment of positive behaviors.

7. Discuss general issues related to treatment of disruptive behavior disorders.

Deviant child behavior in early childhood predicts later delinquent behavior. Insecure attachment relationships in infancy will also predict later behavioral problems. The 4 variables most predictive of adolescent delinquent behavior are mother’s permissiveness for aggression, mother’s negativism toward child, child temperament, and parent’s use of power-assertive methods (corporal punishment and coercion). Persistent tantrums, aggressive behavior, and noncompliance are not passing “phases” that will grow out.

Parental training for treatment for disruptive behavior disorders is empirically supported. Typically, treatment uses multiple modalities such as multisystemic therapy to teach parents to get in contact with school, family, and community rresources. Parents and all adults involved in child’s care typically meet and clearly state and enforce behavior expectations, agree on rewards for good behavior and consequences for misbehavior, and resolve abuse, neglect/lack of supervision, family violence/conflict issues.

Individual therapy for the child is sometimes used to address social problem-solving, aggression/anger management, and comorbid disorders/symptoms but have limited potential in treatment of disruptive behavior disorders. Medication is sometimes used to treat explosive aggression.

8. Provide examples of the early manifestations of future aggressive behavior and related prognostic issues.

Early cognitive manifestations of future aggressive behavior include social cognitive deficits (i.e., poor understanding of social interactions, problems with group entry, etc), inability to generate multiple plausible solutions to problems, attribute hostile intent of others with aggressive behavior, and a belief/attitudes system that favors verbal and physical aggression (i.e., “its ok to yell, argue, and beat the shit out of you if I don’t get my way).

Maltreated children develop rejection sensitivity that places them at risk for emotional and behavioral problems. It is often accompanied with anticipatory emotional arousal to anxiety or anger. Impulsivity and attention problems in childhood are predictive of behavior problems and delinquency.

Children with untreated disruptive behavior disorders are at a heightened risk for multiple problems. As children and adolescents, they are at risk for rejection from peers, abuse, school dropout, delinquency and early legal involvement, and conduct disorder. As adults, they are at risk from alcoholism and substance abuse, depression, adult crime, antisocial personality disorder, and marital problems.