Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Disruptive, Impulse Control and Conduct Disorders; Neurodevelopmental Disorders (Pearls)

NEURODEVELOPMENTAL DISORDERS
Attention-deficit/hyperactivity disorder An 8-year old who is disruptive in class, always fidgeting, has difficulty concentrating and does not complete assignments

Characterized by problems paying attention, excessive activity, or difficulty controlling behavior which is not appropriate for a person's age

  • Hyperactivityimpulsivity, or inattentiveness manifesting prior to age 12 years
  • > 6 symptoms of inattention, hyperactivity-impulsivity, developmentally inappropriate and duration of symptoms > 6 months
  • Symptoms must occur in more than one setting (example school and home)

Treatment: Stimulants (methylphenidate, mixed amphetamine salts)

Autism spectrum disorder A child has normal cognitive development, poor relationships and does not spontaneously seek activities with others - Asperger disorder

Disruption of social interaction and language at age 3 or earlier - Autistic disorder

A range of conditions classified as neurodevelopmental disorders. Individuals diagnosed with autism spectrum disorder present a developmental delay in socialization, language, and cognition

Autism spectrum disorders (ASD) encompasses

  • Autistic disorder
  • Childhood disintegrative disorder
  • Pervasive developmental disorder-not otherwise specified
  • Asperger disorder

DSM V criteria

  • Social communication and social interaction deficit in many contexts such as
    • Lack of social-emotional reciprocity
    • Lack of nonverbal communicative behaviors
    • Impairment in developing, maintaining, and understanding relationships
  • Restricted and repetitive patterns of behavior, interests, or activities such as
    • Motor movements that are stereotyped or repetitive (e.g., flipping objects)
    • Inflexibility to change
    • Restricted and fixated interests - these are typical with abnormal intensity or focus
    • Hyper- or hyporeactivity or unusual interest in a sensory stimulus (e.g., fascination with lights)
  • These symptoms must be present in the patient's early developmental period in the absence of an organic etiology (e.g., hearing dysfunction)
  • These symptoms cannot be better explained by other conditions (e.g., intellectual developmental disorder)

Treatment:

  • Refer – Autism specialists, speech & language pathologist
  • Audiology evaluation, +/- EEG
  • Behavioral therapy
  • Medications:
    • Second generation antipsychotics (risperidone, aripiprazole) for aggression/hyperactivity, mood lability; can also use haloperidol, carbamazepine
    • SSRIs for stereotyped/repetitive behavior
DISRUPTIVE, IMPULSE-CONTROL AND CONDUCT DISORDERS
Conduct disorder A child is referred to your office for unusual animal cruelty and bullying at school

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

  • Manifested by the presence of at least three of the following 15 criteria in the past 12 months
  • From any of the categories below with at least one criterion present in the past 6 months
  • It is often seen as the precursor to antisocial personality disorder, which is per definition not diagnosed until the individual is 18 years old

Aggression to People and Animals

  • Often bullies, threatens, or intimidates others.
  • Often initiates physical fights.
  • Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
  • Has been physically cruel to people.
  • Has been physically cruel to animals.
  • Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
  • Has forced someone into sexual activity.

Destruction of Property

  • Has deliberately engaged in fire setting with the intention of causing serious damage.
  • Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

  • Has broken into someone else’s house, building, or car.
  • Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
  • Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious Violations of Rules

  • Often stays out at night despite parental prohibitions, beginning before age 13 years.
  • Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
  • Is often truant from school, beginning before age 13 years.

Treatment:

The most effective treatment for an individual with conduct disorder is one that seeks to integrate individual, school, and family settings. Additionally, treatment should also seek to address familial conflicts such as marital discord or maternal depression.

Oppositional defiant disorder A child is found to back talk and resist following instruction from parents or authorities

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

  • Frequent temper tantrums
  • Arguments with adults and authority figures.
  • Does not conform to rules and regulation
  • Intentional exasperation of others
  • Easily annoyed by others.
  • Revenge-seeking & vindictiveness
  • Angry attitude
  • Harsh and unkind.

Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit.

Treatment:

Psychotherapy: is aimed at helping the child learn to express and control anger in more appropriate ways.

  • Cognitive-behavioral therapy aims to reshape the child's thinking (cognition) to improve problem-solving skills, anger management, moral reasoning skills, and impulse control.
  • Family therapy may be used to help improve family interactions and communication among family members. Peer group therapy might also be helpful

Pharmacotherapy to control ODD include mood stabilizers, antipsychotics, and stimulants.

  • Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.
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