Ch 38 - disorders presenting in middle childhood or adolescence

DSM criteria for ODD
4 or more of the following
- often loses temper
- argues with adults
- actively defies or refuses to cmoply with adults requests or rules
- blames others for his or her mistakes or misbehavior
Sx of ODD
Tendency of the subject to blame others for his or her own transgressions/omissions
- the aggression is predominately verbal rather than physical (reactive rather than proactive)

- families are highly stressed (mom depressed)
> when they set limits - (children react defiantly and it ends in harsh physical punishment)
> lack of positive reinforcement

usually evident before age 8, milder form of conduct disorder
- child has a "chip on their shoulder"
- tobacco use is likely as is alcohola nd substance abuse
- different than ADHD, coexists?
- Oppositional behavior is common during adolesence. When such behavior is severe, is is usually a manifestation of family dysfunction
Conduct disorder DSM Criteria
3 or more of the following:
- aggression to people and animals
- bullies threatens or intimidates others
- often initiates physical fights
- has used a weapon
- physically cruel to people
- physically crueal to animals
- destruction of property
- enagaged in fire setting
- destroyed other's property
- decietfullness or theft
> has broken into somone else's house beuilding or car
> stolen items of nontrivial volue without confronting a civtim
- serious violations of rules;
> run away from home overnight at least twice while living in parenteral home
Conduct disorder in General
- must be distinguished from transient antisocial behavior that reflects the risk taking and group contagion that are part of normal adolescence
- (antisocial behavior is common and requres no psychiatric attention)
- Conduct disorder represents severe, persistent and pervasive dysfunction
Clinical Findings with Conduct disorder
they may be intolerably disruptive or dangerous at home, in school or in the community
Medication for Conductive Disorder
Methylphenidate = reduces defiance, oppositionalism, aggresssion, and mood changes for 5-8 yrs

Divalproex = reducing hyperarousal, anger and aggressiveness in incarcerated adolescents. Particularly effective w/agression related to PTSD

lithium - reduces aggressiveness

oppositional defiant disorder usually precedes conduct disorder - only 25% of preschoolers with ODD progress to conduct disorder
ADHD - DSM criteria
6 or more of the following for 6 months
- inattention (makes careless mistakes)
- does not listen
- avoids tasks requiring sustained attention
- hyperactivity
- fidgets or squirms
- often leaves seat
- impulsion
- often blurts out answers
- difficulty waiting turn
ADHD general
high incidence of first degree relatives with ADHD

- Central physiologic mechanisms appear to consist of dysfunction of dopaminergic pathways involving the connections among basal ganglia, the limbic system and the frontal and prefontal cortex's

= single most common chronic behavior disorder in preadolescent children

- higher rates are found in inner city populations. more common in boys than girls for the predominately hyperactive impulsive type and 2:1 for the predominately inattentive type
Clinical Findings ADHD
hyperactivity and impulsivity tend to b/c less apparent as children get older and attention and cognitive problems move to the foreground

- secondary sx such as perceptual and emotional immaturity poor social skills may be observed

- academic under achievement is further enhanced by commonly comorbid lanugage an dlearning disorders

- disruptive and impulsive behaviors perist

*distinguishing inattention from absence sizures is a consideration in the DD

Social Hx for ADHD
- parents of hcildren with ADHD have an increased rate of psychopathology and marital discord

- mothers have been found to be depressed

- father show increased problems with antisocial behavior and job instability
Treatment for ADHD
stimulant meds - pscyostimulants (DOC)
= methylphenidate - most common
= dextroamphetamine and pernoline - less common

undocumented treatment
- no report of dietary effects of sugar and food additives on behavior except in small percent
> Megativtamin = ineffective and dangerous
Prognosis and course of ADHD
> formal schooling -= most difficult stage in life. later stages - ppl find occupational or edicaiotnal niches that commodate their behavior and cognitive idiosyncracies
Clinical Finding ADHD

want to sleep in parenteral bed

refuse to be alone

plead not to go to school

time to go to school children complain of abdominal pain, N/V, diarrhea, urinary frequency
Gender Idienty disorder - DSM
persistent cross gender identification
- repeated stated desire to be or insistence that or she is the other sex
- strong persistent preferences for cross sex roles in make believe play
- intense desire to participate in teh sterotypicla games and pastimes of other sexes
- frequent passing as the other sex
Conditions with Gender Identity Disorder
Boys: assertion that his peins or testes are disgusting or an aversion of rough and tumble play

Girls: rejection of uriation in a sitting position, assertion that she will grow a perins, or an assertion that she does not want to grow breasts or menstruate

Disturbance is not concurrent with physical intersex condition

window of psychological vulnerability between 21/2 - establish gender identification and 6 when he or she recognizes gener assignment is stable

grow up with homosexual behaviors

- no evidence that early intervention with change sexual orientations, but early intervention may reduce subsequent gender dysphoria and transexualism