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59 Cards in this Set
- Front
- Back
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Prevalence of Disruptive Behavior Disorders
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* 12% of children under age 18 meet diagnostic criteria for at least one psychiatric illness
* Reported incidence varies: - ADHD 4-12% - CDO 4-12% - ODD 2-16% |
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Risk Factors Affecting Children for Disruptive Behavior Disorders
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- crime & violence
- poverty - lack of values - low esteem - use of drugs and alcohol - lack of education - inadequate information - other family factors such as mental illness |
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Disruptive Behavior Disorders: Psychosocial "Influences"
(These are components that can be controlled. Genetic factors cannot) |
* Resiliency
- Protective factors * Attachment - parent/child bond - the stronger the bond, the more likely they will make positive relationships with others and be a more secure person * Behavioral - Respondent conditioning (learned behaviors) - Operant conditioning (rewards and consequences) * Cognitive - Information processing * Family systems |
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Disruptive Behavior Disorders: Temperament
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- Temperament reflects how we think
- Related to basic emotions and motivations - Basic dispositions are unique - May change with development - Goodness of Fit: child vs parent temperament |
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Observation of Temperament
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- activity
- adaptability - approachability - intensity/mood/sensitivity |
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Disruptive Behavior Disorders: Biological Theories
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- Underactive NE and Dopamine
- Underacitve 5HT b/c it follows NE |
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What do medications used to treat ADHD do to NE, 5HT and Dopamine levels?
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- They increase NE, 5HT and dopamine
- Children who have ADHD and are under stress are better able to concentrate b/c stress increases NE and dopamine naturally. |
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Disruptive Behavior Disorders: Organic Correlates
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* Maternal health (perinatal)
- drinking, smoking, illness during pregnancy * Early infancy brain insults - Low apgar scores * Trauma |
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Etiology summary of Disruptive behavior disorders
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* they are heterogeneous behavioral disorders with multiple possible etiologies
- Environmental factors - CNS insults - Neuroanatomical/ Neurochemical - Genetic origins |
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Definition of ADHD
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* Developmentally inappropriate poor attention span or age-inappropriate features of hyperactivity and impulsivity or both
- 61% combined type - 30% predominant inattentive - 9% predominant hyperactive-impulse |
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Inattentive Symptoms (need 6)
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- Forgetful
- Often loses things - Difficulty organizing - Often does not seem to listen - Distracted by extraneous stimuli - Fails to give attention to details - Difficulty staying on task - Fails to finish schoolwork or chores - Hesitant to engage in tasks that require sustained mental effort |
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Hyperactvity/Impulsivity (need 6)
(impulsiveness means not thinking about the consequences before acting) |
- Fidgety
- Unable to sit still - Runs about or climbs excessively - "on the go" - Talks excessively - Difficulty engaging in leisure activities - blurts out answers - has difficulty waiting turn - Interrupts and intrudes on others - Frequently has poor social boundaries - Outbursts/aggression (due to frustration) |
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Epidemiology of ADHD in Children and Adolescents
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* More frequent in males than females
- 4:1 general population - 9:1 clinic population * First born boys most common * First degree relative risk, particularly fathers * High prevalence of other familial d/o |
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Clinical Features of ADHD
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* School
- decline in academics - sloppy work - due to inattentiveness * Peer relationships - difficult b/c they may have poor social interactions - other kids may tease them * Parental relationships - goodness of fit/temperament - parents who are not educated about ADHD may feel that their kids are simply being defiant or bad on purpose |
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Other Associated Features with ADHD
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- Low self-esteem
- Developmental delays b/c of inattentiveness or b/c of a corresponding condition - Depression secondary to frustration - Learning disabilities - Conduct disorders may develop b/c of impulsiveness - Substance abuse b/c of the need for some kind of coping |
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Potential Areas of Impairment with ADHD
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- Academic limitations
- Relationships - Low self esteem - Injuries - Smoking and substance abuse - Motor vehicle accidents - Legal difficulties - Occupational/vocational |
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ADHD comorbidities
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- 35.2% oppositional defiant disorder
- 25.7% conduct disorders - 25.8% anxiety disorders - 18.2% mood disorders - learning disabilities: no definitive data reported range 12-60% |
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Course and prognosis of ADHD
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- symptoms may be observed in
infants and toddlers - diagnosed during elementary school - stable through early adolescence - symptoms often dissipate late adolescence/early adulthood - minority continue with full symptoms into mid-adulthood - others may retain some symptoms (partial remission) |
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Definition of oppositional defiant disorder
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* Enduring pattern of negative, hostile and defiant behavior
* Behavior is directed toward those well known to the individual - Usually directed towards an authority figure which most often happens to be a parent * Absence of serious violation of other people's rights - child doesn't willingly and knowingly harm other people. This is what distinguishes this from conduct disorder |
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Oppositional Defiant Disorder: Epidemiology
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* before puberty: boys > girls
* After puberty: boys = girls * Influences: - temperamental predisposition - parental patterns of control, power, struggles with autonomy - family Hx: antisocial PDO, substance use |
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ODD Clinical Features
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- Refuses to comply with requests of others
- Irritable and easily annoyed - Angry, resentful, often loses temper - Blames others - Deliberately annoys others - Spiteful and vindictive - Symptoms may not be evident outside home: see more in the home rather than at school |
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ODD Differential Dx's
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- normal, adaptive
- adjustment d/o - ADHD - Features occur during illness |
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ODD course and prognosis
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- Usually prior to 8 years old
- S&S emerge in home - Gradual onset - About 25% have a very good prognosis b/c of good intervention - If not treated, may progress to conduct d/o |
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Definition of Conduct Disorder
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* Repetitive and persistent pattern of behavior in which:
- the basic rights of others are violated (burglary, stealing cars, etc) or - major age-appropriate societal norms or rules are violated |
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Conduct Disorder: Epidemiology and Etiology
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- 6% to 16% of boys
- 2% to 9% of girls - Childhood onset type is often preceded by ODD (before the age of 10) |
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Conduct Disorder: Environmental Factors
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- psychopathology
- substance dependence - neglectful and abusive - chaotic conditions - may see an angry and negative environment surrounding the child - Will see that the child has experienced a lack of caring |
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Conduct Disorder Clinical Features
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- bullies and threatens others
- lying, cheating and stealing - truancy and runaway behaviors - poor academic achievement - use of tobacco, ETOH or other drugs - lack of guilt, empathy or remorse - physical cruelty to animals and people - start fires |
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Conduct Disorder Diagnostic Criteria
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* Three or more criteria in past 12 months, at least one present in past 6 months
- Aggression towards people or animals - destruction of property - deceitfulness or theft - serious violation of rules |
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Conduct Disorder prognosis
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* Poor
- young age onset - high number of symptoms - high number or frequency of symptom expression - comorbid conditions * Good - Mild disorder - normal intellectual functioning - absence of coexisting conditions |
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ADHD Diagnostic Guidelines
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- 6-12 yo
- Must meet DSM 4 criteria - Requires evidence from caregivers - Requires evidence from classroom teacher - Include assessment for coexisting conditions |
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Disruptive Behaviors: System Assessment (health history)
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* History and observations of
- organic correlates - potential behavioral concerns - family assessment - school assessment |
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Disruptive Behaviors: System Assessment (Family)
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- Presenting problem and health history
- Developmental history - Brief genogram - Family health issues - Perception of school performance - Method of discipline - Child's ADLs - Social functioning |
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Disruptive Behaviors: Family Assessment Includes...
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* Documentation should include
- multiple settings - age of onset - duration of symptoms - degree of functional impairment |
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Disruptive Behaviors: School Assessment Includes...
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* Documentation of specific elements
* Evidence of schoolwork - report card, samples of work * Teacher narrative including - classroom behavior - learning patterns - classroom interventions - degree of functional impairment |
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Disruptive Behaviors: System Assessment and Physical Examination
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* In addition to complete physical examination
- complete neurological exam - vision/hearing screening |
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Priority Nursing Diagnoses: ADHD, CDO and ODD
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- risk for injury: self and/or others
- low self-esteem - impaired social interaction - ineffective individual coping - risk for ineffective family coping |
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Disruptive Behaviors: treatment focus
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* Individual
- self-esteem - peer relationships - self-control - empowerment * Parenting - Education - Developmental tasks - Child advocate * School involvement - team appraoch - assessment tools - teacher education * Other - educational placement - structuring |
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What is the best way to ensure a positive prognoses for kids with Disruptive Behaviors
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- Positive family involvement
- Parents need EDUCATION and need to learn when they should take a break |
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Disruptive Behaviors: General Psychosocial Interventions
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- Play therapies: behavioral, mutual story telling, structured and nondirective play
- Cognitive therapies: beliefs, changing negative thoughts about themselves - Behavioral therapies: rewards and consequences - Self-care management: empowerment, anxiety reducing skills - Group therapies: esteem, social interaction - Family therapies/counseling: education |
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Individual Interventions: Risk for injury
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- basic safety education
- identify emotional/situational triggers - limits (avoid power struggles) - redirect towards non-destructive behaviors - strategic removal - reward system (operant conditioning) - appeal to fairness |
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Individual Interventions: Impaired Social Interaction
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- Positive role model
- Identify patterns - Education - Feedback and alternatives: positive feedback needs to happen right away - Rewards and consequences (operant) - Role playing |
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Individual Interventions: Low self esteem
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- Acceptance and positive regard
- Opportunities for success - Recognition and positive reinforcement for attempts and successes - Set limits on manipulative behaviors - Child needs to know that they are liked. It's their actions that people have a problem with |
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Individual Interventions: Ineffective coping
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- Simple concrete instructions
- Limit distractions within environment - 1:1 assistance with gradual decrease - Education regarding feelings and behaviors - Immediate non-threatening feedback - Role play |
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Psychotropic Medications and children
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- Often differ in response to medications
- May metabolize medications more rapidly - Final maintenance dosages may be higher than those used for adults - Controlled studies are lacking |
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Will children need more or less of psychotropic medications in comparison to adults?
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More b/c they metabolize the medication more quickly
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ADHD Specific Pharmacological Treatments in order of effectiveness of symptom control
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- CNS stimulants
- Strattera (Atomoxetine): affects NE specifically and there's not the stimulant effects - Antidepressants (second line Tx): not approved for ADHD, but they are still used |
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Psychostimulants
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* Found to be effective over placebo in approximately 90% of patients
* Increases: - vigilance and attention - short term memory * Decreases: - motor activity - impulsiveness - emotional lability - stimulants create the brain to be more active which increases their attention and betters their behavior |
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What do stimulants not do?
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They do not cause children to be sedated
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Methylphenidate HCl
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* CNS stimulant (Schedule II)
* Action: unknown. Improves impulse transmission by releasing stored NE and DA, and inhibits reuptake - More NE with a decreased uptake means more NE is available for a longer period of time * Hypothesized sites: cortex and reticular activating system * Not a pradoxical reaction |
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What area of the brain does Methylphenidate HCl work on?
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Cortex and reticular activating system
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Adverse Effects of Methylphenidate HCl
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- Growth suppression (suppresses appetite)
- Delayed sleep (don't give before meals or bedtime) - HA, Stomachaches, irritability - May unmask or exacerbate tic d/o - seizures - arrhythmias, anginal pain, hypertension, sudden death |
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What does the American Heart Association recommend for children taking Ritalin?
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That they get EKG's done and that those who have cardiac defects not be on it b/c of it's ability to cause arrhythmias and anginal pain
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What is the concern with Ritalin for children who experience psychotic symptoms?
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Ritalin increases their dopamine more.
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Examples of Ritalin Dosing
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* Children
- 10 mg 08000 and 12000 - 5 mg @ 1600 if needed - SR: 20 mg QAM - Concerta (ER) - Titrate 5 to 10 mg increments up to 60 mg * Adults - 10 mg BID to TID AFTER meals |
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Adderall XR (mixed salts of a single-entity amphetimine)
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- blocks reuptake of NE and Dopamine
- XR taken QD - contains immediate and delayed release - Common SE's: loss of appetite, insomnia, weight loss, emotional lability, depression * removed from canadian market February 2005 |
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Strattera (atomoxetine HCl)
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- selective NE reuptake inhibitor
- non stimulant - QD or BID capsule - SE's similar to TCA's (SLUD) - increased risk of suicide - WARNING!!! potential for severe liver injury |
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TCAs (Nortriptyline, Imipramine and Desipramine)
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- if stimulants ineffective or not tolerated
- coexisting anxiety or depressive d/o - family Hx of mood s/o - FIRST choice |
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Clonidine
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- decreases excessive hyperactivity
- has a calming effect - does not improve inattention symptoms - may be useful with insomnia. Monitor BP |
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Medication Phases
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* Titration: start low, go slow, working up to appropriate dosage
* Sculpting: sculpt to meet individual needs * Maintenance: assess regularly and consider the need for holidays |
