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Attention deficit hyperactivity disorder (ADHD) and conduct disorder/problems

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Title: Attention deficit hyperactivity disorder (ADHD) and conduct disorder/problems


1
Attention deficit hyperactivity disorder (ADHD)
and conduct disorder/problems
  • Paul McArdle

2
The true measure of a nations standing is how
well it attends to its children their health
and safety, their material security, their
education and socialization, and their sense of
being loved, valued, and included in the families
and societies into which they are born.
Unicef (2007) Child Well-Being in Rich Countries.
Innocenti Research Centre http//www.unicef.ca/por
tal/Secure/Community/502/WCM/PRESS/IRC7/RC7.pdf
3
ADHD history
  • Moral disorder
  • Still 1905
  • Minimal brain damage - 1950
  • Hyperkinetic syndrome
  • Ounsted 1955
  • Attention deficit disorder with hyperactivity
  • American Psychiatric Association 1981

4
Diagnostic symptoms
  • Inattention
  • Over- or hyper-activity
  • impulsivity

5
symptoms
  • Inattention
  • Often fails to give close attention to details,
    makes careless mistakes
  • Has difficulty sustaining attention in tasks or
    play
  • Does not seem to listen
  • Fails to finish tasks
  • Often avoids sustained mental effort
  • Often forgetful, loses things
  • Easily distracted by extraneous stimuli
  • Difficulty organising tasks and activities

6
Symptoms II
  • Hyperactivity/impulsivity
  • Often fidgets,
  • Leaves seat in classroom
  • Often runs about or climbs excessively in
    situations in which it is inappropriate
  • Is on the go as if driven by a motor
  • Talks excessively

7
Symptoms II
  • Hyperactivity/impulsivity
  • Often fidgets,
  • Leaves seat in classroom
  • Often runs about or climbs excessively in
    situations in which it is inappropriate
  • Is on the go as if driven by a motor
  • Talks excessively
  • Often blurts out answers
  • Has difficulty waiting turn
  • Often interrupts or intrudes on others
  • Runs out in the street, goes off with strangers

8
Further criteria
  • Early onset before 7 years of age
  • Present in more than one setting
  • Clear evidence of ...significant impairment in
    social, academic or occupational functioning

9
How common is ADHD
  • 5 is usual US figure
  • More boys than girls
  • But less in non-urban and more traditional
    societies.
  • Of 2048 adolescents interviewed in Goa, 4 had
    ADHD!
  • Pillai et al (2008) Non traditional lifestyles
    and prevalence of mental disorders in adolescents
    in Goa, India. British Journal of Psychiatry
    192(1)45 51.

10
Associated features
  • Rejection by peers
  • Rigid insistence on requests being met and
    bossiness
  • Learning and communication disorders
  • Tics and Tourette's syndrome
  • Increased accidents, including driving accidents
    and fatal crashes
  • Mood lability, unhappiness, demoralization
  • Antisocial behaviour, substance misuse, crime
  • Barkley RA. Cox D. A review of driving risks and
    impairments associated with attention-deficit/hype
    ractivity disorder and the effects of stimulant
    medication on driving performance. Journal of
    Safety Research. 38(1)113-28, 2007.

11
Even if IQ is unaffected
  • Children with ADHD
  • Cannot
  • Concentrate, communicate, read and write,
    self-organize, befriend and play to the same
    level as other children of the same age
  • Are often judged by parents to be at greater risk
    than others and
  • Are typically distressed and unhappy even to the
    degree of 'clinical depression'

12
What is thought to be the cause of ADHD
  • Nature a neurological or brain condition
  • Nurture a product largely of environment (but
    perhaps also affecting brain development)
  • Both nature and nurture both brain and
    environment

13
Further ADHD comorbidity
  • With pragmatic language/ social interaction
    deficits similar to PDD
  • Geurts et al (2004) Can the Childrens
    Communication Checklist differentiate between
    children with autism, ADHD and normal controls?
    JCPP (45) 1437-1453
  • Bishop Baird (2002) Parent and teacher report
    of pragmatic aspects of communication. Use of the
    CCC in a clinical setting. Developmental Medicine
    and Child Neurology 43809-818
  • Gilmour J. et al (2004) Social communication
    deficits in conduct disorder a clinical and
    community survey. JCPP 45(5)967-78.

14
A neurological/brain condition
  • Executive function deficit, deficit of frontal
    cortical functioning
  • 'goal directed behaviour'
  • Barkley et al (1997) ADHD and the Nature of Self
    Control New York Guilford Press
  • Working memory deficits
  • Rapport MD. et al (2008) Working memory deficits
    in boys with attention-deficit/hyperactivity
    disorder (ADHD) the contribution of central
    executive and subsystem processes. Journal of
    Abnormal Child Psychology. 36(6)825-37.

15
Trends CD and comorbidity
16
Increased disturbance parental report
Collishaw et al (2004) JCPP 45 1350-1362
17
Increased disturbance self-report
West Sweeting 2003 JCPP 44399-411
18
Trends GHQ scores west of scotland
19
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20
Mortality 15-19 year olds
21
ADHD and CD
  • 'ADHDCD is a quantitative variant of
    ADHD-related behaviours
  • Thapar 2001
  • Heritability of antisocial behaviour is mediated
    by a callous unemotional trait (Viding et al
    2005)
  • Also
  • Gene environment correlations gene-environment
    interactionsGenetic influences are strong and
    pervasive but rarely determinative
  • Rutter 2002

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Shaw et al 2008 Proceedings of the National
Association of Science
26
Nature
  • Brain
  • injury trauma, anoxia or chemical
  • Development affected by genetic factors
  • E.g. Martin et al (2002) Observer effects and
    heritability of childhood ADHD symptoms British
    Journal of Psychiatry 180260-265

27
Nurture
  • Extreme early deprivation
  • 'neurodevelopmental programming'
  • Stevens et al (2008) inattention/overactivity
    following severe early institutional deprivation
    presentation in early adolescence. Journal of
    Abnormal Child Psychology 36(3)285-293.

28
Nurture
  • Extreme early deprivation
  • 'neurodevelopmental programming'
  • Stevens et al (2008) inattention/overactivity
    following severe early institutional deprivation
    presentation in early adolescence. Journal of
    Abnormal Child Psychology 36(3)285-293.
  • Subtle deprivation

29
Subtle deprivation
  • A major study by Play England, part of the
    National Children's Bureau, found that 51 of
    children had been stopped from climbing trees,
    21 from playing conkers and 17 from playing
    games of tag and chase... 'Children are not
    allowed the freedoms that were taken for granted
    when we were children'
  • Observer Aug 3rd 2008

30
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32
Subtle deprivation
  • 'In the West, children are not only socialized
    into a system that promotes individualism,
    competitiveness, and inequality and rejects forms
    of authority but also have to live in the
    unstable family structures such an ideology
    produces (including) ..ambivalence towards
    children'
  • Timimi S (2005) the effect of globalization on
    children's mental health BMJ 33137-39

33
Subtle deprivation
  • 'In the West, children are not only socialized
    into a system that promotes individualism,
    competitiveness, and inequality and rejects forms
    of authority but also have to live in the
    unstable family structures such an ideology
    produces (including) ..ambivalence towards
    children'
  • Timimi S (2005) the effect of globalization on
    children's mental health BMJ 33137-39
  • Highest rates of disorder among those with
    non-traditional life-styles
  • Pillai et al 2008

34
Later perpetuating or aggravating factors
mechanism
  • social and executive function demands of late
    adolescence overload the late developing
    prefrontal cortex, giving rise to prefrontal
    dysfunction and a lack of inhibitory control over
    antisocial, violent behavior that peaks at this
    age
  • Raine (2002) The role of prefrontal deficits, low
    autonomic arousal, and early health factors in
    the development of antisocial and aggressive
    behavior in children JCPP43410434

35
ADHD and creativity
  • His most extraordinary quality was his titanic
    energy. He could not sit still or stay long in
    the same place. He walked so quickly that those
    in his company had to trot to keep up with him.
    When forced to do paperwork, he paced around a
    stand up desk. Seated at a banquet, he would eat
    for a few minutes, then spring up to see what was
    happening in the next room or to take a walk
    outdoors When he had been in one place for a
    while, he wanted to leave The most accurate
    image is of a man who throughout his life was
    perpetually restless, perpetually in movement.
    From Peter the Great by Robert K Massie.

36
ADHD and creativity
  • His most extraordinary quality was his titanic
    energy. He could not sit still or stay long in
    the same place. He walked so quickly that those
    in his company had to trot to keep up with him.
    When forced to do paperwork, he paced around a
    stand up desk. Seated at a banquet, he would eat
    for a few minutes, then spring up to see what was
    happening in the next room or to take a walk
    outdoors When he had been in one place for a
    while, he wanted to leave The most accurate
    image is of a man who throughout his life was
    perpetually restless, perpetually in movement.
    From Peter the Great by Robert K Massie.

37
treatment
  • Structure and support in school
  • Opportunities for active play
  • Mentors
  • Parent training
  • Supportive medication
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