Chapters Transcript The Evaluation of ADHD & Disruptive Behavior Disorders Max Rosen, MD, presents on the epidemiology, pathophysiology, clinical presentation, evaluation and management of disruptive behavior disorders. I am an assistant professor of Psychiatry within the, within the division of Child and adolescent Psychiatry here at Wash U. And I was invited to speak to your group tonight and I'm really excited uh to get the chance to share a little bit of my work and my um and my um expertise in this area. Um Though I always claim that uh I'm always trying and continuing to educate myself and to learn more, but I do have a particular interest within the field of A DH D. Um And so I will be going through the evaluation of A DH D and disruptive behavior disorders with an emphasis on uh the evaluation as well as the treatment. Um as was said at the start, please interrupt me or put any questions in the chat and I'll and I've uh and or, and I'll be sure to get to those at the end as well. Uh Just as a matter of disclosure, I have nothing significant to disclose other than an authorship in the Carle Child uh report which I received a small um a small uh or a small or an honorarium. Um but it has nothing to do with this topic. So, here are our goals and objectives for tonight. So we will, uh or so, my primary goal is to be able to enable uh you all as providers as pediatricians to evaluate the signs and symptoms that are related to uh disruptive behaviors, including offering the 1st and 2nd line treatment options for a DH D. Um And, and I'll do that by uh or so by being able to differentiate between the epidemiology. The, so the pathophysiology, the clinical presentation, the evaluation and the management of disruptive behavior disorders. So, uh why do I start with the term of disruptive behaviors um as a child psychiatrist myself and as and as or as pediatricians or other uh pediatric providers um on this call, um we often get asked a lot uh about, about a child's uh um so outburst tantrums of behaviors. And so this is actually a specific DS M five category um which is the disruptive uh impulse control and comic disorder. As you can see, actually, a DH D is not included in this. Um A DH D is itself viewed as a neurodevelopmental disorder. As you can see the disruptive impulse controlled comic disorder. Um Specific diagnoses include um oppositional um or oppositional disorder, chronic disorder, intermittent explosive disorder and pyromania kleptomania. What is uh what is the same about a lot of these is that actually that they're presenting signs and symptoms are often trans diagnostic and So, uh we as uh or pediatric providers will often get asked about this kiddo's irritability, their aggression, their anger. And so parents often do a report on this irritability, anger, aggression or, or, and violence. And this is up to us as uh providers to be able to or determine um at least at the start where is the diagnostic category because that can and does um uh or sort of implicate uh what we offer as uh treatment options. Um But as you can see, a lot of other diagnostic categories involve this irritability, aggression, anger, which includes those nerve or developmental disorders, including A DH D and autism, as well as um anxiety disorders. And uh person of pediatric groups often present as an irritability or having tantrums as well as the often overlooked um especially in the younger group. But a lot of research here at was you looks at this preschool and early childhood or age and has proven that that. So that kid is as young as preschool age can have depressive disorders including or a major depressive disorder as well as a disruptive mood dysregulation disorder or D MD D. So I'm gonna start with a DH C and we'll go through from there. Um uh or as you all may or may not know um A DH D is this persistent pattern of inattention and or hyperactivity which interferes with the functioning to classify for a diagnosis of A DH D A child has to meet the uh the diagnostic criteria of six out of nine criteria. Um either for inattention and or for hyperactivity impulsivity. The essential feature of A DH D is this persistent pattern of inattention and or hyperactivity. It is a neurodevelopmental disorder which means it begins in childhood. Um And actually in DS M five, they however, have pushed back the age from um or from 10 to 12 because especially for uh or so for girls with a DH D, there was a realization that a lot of girls weren't presenting uh until a later onset because they often present more with intention or less of the behavior problems that we often see in the boys that we see with a DH D. Um it these or so these impairments must occur in more than one environment including home school, work activities, sports, whatever it may be. Um Typically the symptoms that vary depending on the context within a given setting. So the signs of a disorder may be a minimal or acid when an individual is receiving frequent rewards for appropriate behavior or engaged in interesting activities or has external stimulation like with electronic screens, for example. So uh I'm gonna put these up just so you all are aware of the different inattentive symptoms and these are screened. We'll go through the screening tools in just a second. But that, but that then inattention itself often or it manifests that behavior in the A DH C as a wandering off task, lacking persistence, having a different, sustaining a focus and being disorganized, but it's not due to a defiance or just a lack of comprehension as may be expected. And um either oppositional defiant disorder or uh or, or in an intellectual disability. So again, as you can see up on the screen, it includes this kind of inability to pay close attention, making a lot of mistakes. They seem to not uh uh or listen, they seem to be unable to follow through with, with chores. I often will ask parents um again, depending on the age, if you give a child, two or three tasks such as go upstairs, brush your teeth, put on your clothes and get your shoes on how or how likely or not. Are they uh to start that and maybe get the first thing done but not to get the second or three. Again, you have to gauge that base off at the age of the child. But uh those are some examples of some questions that I ask. They often um and as these inattentive symptoms continue on into adulthood, they often do look like uh challenges with organization. They jump from task to task without completing tasks, they often will avoid tasks that do require consistent or, or, or or mental effort. So I often ask uh parents or kids in school, especially for like a writing assignments, for example, where they make it more off task more easily. Um Oftentimes I'll hear about kids that just avoid those tasks altogether or they just uh rush through and put down kind of like a random answers because, um, because they know that the effort with which they need, um to be able to do the task completely is or is beyond their capability. Uh These kiddos with inattentive a she often will lose objects that are required for their tests. Um So their or their water bottles, their school books, their sports equipment, they're often easily distracted and then they're often a forgetful and their routine activities as far as the hyperactive and the impulsive symptoms. So, you know, these are your kind of stereotypical. Um So boys with a DH D that just have a really hard time being able to stay still hyperactivity, I refers to this excessive or, or, or motor activity such as a child like you're running about when it is inappropriate or excessive tapping or fidgeting or talkativeness. Um And or in situations where it may be inappropriate, um They may be difficult to keep up with. They're always on the go. There's the success of talking. They have difficulty awaiting turns, they blurt out answers too quickly, they interrupt others. So impulsivity again, I refer to this, these hasty actions that occur in the moment without forethought and then have high potential for harm to the individual like sprinting into the street without looking so often while I see kiddos where, where the parents or the caregivers can't keep up with their kiddos. Um, impulsivity may reflect a desire for immediate rewards or an, or an inability to delay their gratification and impulsive behaviors may also, uh present as a social intrusiveness, like interrupting others or, um, or uh making important decisions without consideration of their long term consequences. So, um, I always tell parents and I tell providers, I don't, I don't care as much about their academics. Like if they get A's or B's or C's, I'm not their parent, my job is their clinician. And so the things that I often get worried about, especially the psychiatrist and that often pushes me over the edge and we'll get into the discussion on treatment just a little bit. Um But we push me over the edge to consider an A DH D I got medication is when it's starting to have a lot of the social consequences, especially in uh school age, Children in their elementary years. Um and they start to realize that they're, that they're talking over their friends that they, that they're having this quick to anger and acting impulsively that may start to push away their friends. And so I often will have to rule out autism as a diagnosis because they might look like they are having a lot of challenges in the social realm. Um And so that, and so that may be a reason enough that I discussed with parents about why I would consider putting them on, um, a psycho stimulant that we'll talk about in just a bit, a quick overview of A DH D. Um There's a lot of different reports out there about the prevalence. Uh The best kind of like a data that I've been able to see is really somewhere between uh five, all the way up to 10 or 12% of Children. Um Now, so what are those kind of the, the risk in the prognostic Hector? So, a DH D is associated with a reduced that behavioral inhibition, effort, effortful control or constraint as well as with or negative or emotionality and or elevated uh or a novelty seeking. So I often actually will see a lot of kids that have um or have or voiced either a passive or even active suicidal ideation that their primary diagnosis is not necessarily a depressive disorder, but it's actually a DH D and it's when they're receiving a consequence or when they have that quickness to anger, that impulsive anger um that uh or so that again that they have this kind of negative uh persistence in their like emotional state. These traits may predispose some Children in a DH D but are not specific to the disorder. There are also some environmental risk factors. So including a very low birth weight. So for those of you that take care um of kiddos that are coming out of the NICU, for example, uh a very low birth weight has been shown to convey a 2 to 3 fold risk for a DH D but most Children with, but most Children with low birth do not end up are developing energy. It's just an increase of risk factor. Um Prematurity is also a risk factor although A DH D is correlated with smoking during pregnancies or some of this association may reflect some common genetic risk. And studies of early exposure to maltreatment highlighted the elevated rates of A DH D and abuse and in or neglected individuals who live in care. There has also been association between a DH D and parental stress, inter parental conflict as well as a family discord, but it's not known that these associations are causal or just associations. There is also a genetic risk. So A DH D is elevated in the first degree of biological relatives of individuals with a DH D. Um So the heritability is estimated to be around or 70 to 80%. With the remainder of the variance being found to be caused by unshared environmental factors. While specific genes have been correlated with AD D, they are neither necessary nor sufficient causal factors. Um So, a DH D really is regarded to be kind of a combined product of multiple common genetic variants of small effect um as well as these environmental and temperamental risks that I discussed above. Um There are certain course modifiers. So the family interaction patterns in early childhood are unlikely to cause it but or it may influence its course or contribute to secondary development of comic problems. Um So we talk a lot about parenting um in my uh or in kind of or so my clinic in my world and a lot of kind of harsh and or negative consequences can really um kind of exacerbate a lot of these um A DH D symptoms and also can impact his course over time. There are also gender related diagnostic issues that I kind of uh brought up uh a few slides ago, but A DH D is more frequent in males. So uh or, or then or females in the general population though it's probably um or so I'm over represented uh due to an under appreciation or an under or a diagnosis uh or of girls with a DH D, especially girls with an intent of a DH D. But the ratio has been reported to be about about 2 to 1 in Children. Um but females are more likely than males to present primarily with an attentive aspects like we discussed. So the rule with a DH D and um is that the rule is comorbidity. So in or in the general population odd co which is oppositional defined disorder, cours with a DH D and approximately half of Children with combined presentation of AD D and a quarter of Children with intentive um presentation of a DH D um and Cogic disorder then co occurs in about um or at about a quarter to a half of those um kiddos with um odd though, we'll get into it with just a bit. Um Odd and Cogic Disorder are not the same thing. There's also an increased prevalence of this um irritability or disruptive mood dysregulation disorder, um or so, whatever it's called, there's this impaired emotion of regulation which is often reflected and kind of a slow return to their baseline after an extremely like emotional event. So I often tell people having any kind of like being on a yo yo. So they experience both high highs. So when they're excited, they're really excited, but they also experience really low lows. So when they're angry, they're really angry and they have a slow return to their baseline, they often have overactivity to both positive and to a negative emotional events and together with high trait of or negative emotionality. They may thus be particularly important in those with a DH D who go on to develop chronic disorder. Um So irritability in Children with a DH D is associated with poor uh or functioning across a number of areas including increased rate of comorbidities, particularly with um odd as well as with depressive disorders. Um We know that Children with a DH D had a rape. I I kind of uh tell parents about a third all the way up to a half of kids with A DH D have an increased uh um uh or a rate of, or this kind of like a marked um impulsivity or, or so, not just of their behaviors, but also of their feelings of their emotions, um which is um extremely elevated over the general population. Um And it's so those with that kind of increase in their emotional liability that have poor social um um interactions with their peers, which can lead to depressive disorders. So, why is it common in Children with a DH D? And we'll talk a lot and you'll see, I kind of really harp and stress on this aspect because that's the part that I as a child psychiatrist. I also like, I realize that you all as pediatricians and primary caregivers for our patients often see um more of the bread and butter I A DH D as well. But it's important as primary care providers to also be aware that if a kid is coming in with these concerns for your ability, that that could also be indicative of something like a DH D or MOD D. Um So we know that from studies uh that individuals with uh or so um A DH D are often um undiagnosed or missed with having a learning um or a disorder. So I often um always evaluate or um advocate for an IEP or uh for psychoeducational testing done because uh so the rates from studies have been as high as 80 to 90% of kids though. It's probably more, about half of kids with a DH D have some form of a learning disorder and that's often, um, or missed or under, uh diagnosed. Um, it can range anywhere from 26% for math to 33% for reading and 63% for expression. But again, the numbers are kind of all over the place. If you look at the literature for depression, it's also kind of a mixed bag. Um There's been point prevalences that have ranged from 0 to 45%. And other and in other studies, when controlling for comorbid diagnoses, there is, there is no longer found to be a significant interaction with A DH D and depression. However, I often see kiddos that do have again this uncontrolled or untreated A DH D that then start to internalize the fact that they're having um more negative interactions at school with teachers or with peers or with their parents. And so can start uh to uh or to become internalized as a depressive disorder. We also know that there's increased odds of having an anxiety disorder too which could implicate um treatment, uh choice or selection. I wanted to put in a quick slide um about A DH D and the COVID pandemic, you know, we're clearly now almost exactly at four years um after the kind of the start or the shutdown of or of everything. Um And so the researchers are just like now started to synthesize the findings, the systematic or like a reviews and quantitative meta analysis as more studies have been published. However, the consensus is that and I'm sure you all can tell me just as much if not more than me about these or the significant impact that the pandemic has had um on the exacerbation of the effect on the presentation of these inattentive hyperactivity and impulsivity, uh types of symptoms in Children and adolescents, while the overall effect sizes were small, that it's were statistically significant and, and, and it does indicate an increase in a DH DS symptoms during the pandemic. And it clearly also has an effect on A DH D I medicine consumption. As we've seen, telehealth has been great. Um But it's also, and it's been great that it's increased access, but it also has led to more um A DH D A diagnosis which leads to more treatment for DH D, which leads to a shortage of a lot of the stimulants that we use to treat um A DH D. Um And uh so that has kind of or yielded its own challenges. Um I'm not going to stress too much uh the A DH DS circuitry, but I always like to include the slide. Um And I also bring this up with my parents and or the patients to really, to emphasize and stress that this is a brain disorder. This is not a choice that a patient is having to not pay attention or to not focus or to not stay still. But it really truly is a brain based disorder that it, that has a lot of different uh or circuitry implicated including a pathways. So um you can see up there the different attention pathways, the reward pathways, the thing that I really do talk about, especially as kids get older in age into high schools that executive or are functioning. So we know that in general adolescents make less than ideal decisions and especially those with a DH D that they make even worse decisions at time. Um or so, like not only being able to uh uh or sort of do well and to themselves at school, but to organize themselves in terms of their social world and doing impulsive things. Um and then there is also the motor pathways which is where a lot of the hyperactivity comes from. So we know that they are definitely planning their movements also. So they have the increased baseline motor activity as well as a decreased ability to suppress their motor impulses. And um again, I kind of include hyperlinks to some good like videos that help to explain this to patients as well. So at the end of the day, A DH D is a clinical diagnosis that any clinician in theory can make. Now we all uh as providers understand and know that sometimes insurance or other um or other parties have or have other requirements. So, um as you all probably use your own practice a lot um of the diagnosis of A I DS, you do come down to um uh for being able to seek the Vanderbilt A DH D diagnostic parent and teacher uh via the rating skills. Um These are free um or a measure that are available online. They ask about those core um 18 symptoms of A DH D the nine hyperactive impulsive and the nine unattended symptoms. Um And it's great because there's a parent form that there's a teacher form. Um and uh can help to support a diagnosis of a DH D. There's also the Conners, but there is a cost associated with that. Um And um it doesn't necessarily uh perform or it's not any more sensitive or specific than other Vanderbilt. Um Again, I had a few more slides about emotion regulation dysregulation. So we know that emotion regulation is a broad concept that refers to a set of interrelated processes that drive which emotions an individual has and how he or she experiences and expresses them emotion regulation processes, deal with modifying one's emotional reactions to facilitate advantageous comes in a particular situation. Whereas that dysregulation that we often see kiddos with ADHD occurs when an individual has difficulties keeping their or their or their feelings under control and experiences or express or express their emotions in a manner that is considered inappropriate for his or her developmental age in the social setting. Um So there's lots of ways that we as psychiatrists do um assess for emotion dysregulation. And again, these clinical or descriptions that again, it can be used to describe this emotion dysregulation that's often seen in a DH D, but it can be seen in other things as well as include hot temper that's short fused, low boiling point, frequent outbursts, they shift from normal mood to depression or to mild excitement. About 20 or 30 years ago, there was an increase in the diagnosis of bipolar disorder in Children. And what that seems to represent is that these aren't kiddos and, and so when they track those kiddos with childhood onto that bipolar disorder, um over time, they didn't actually have that bipolar disorder as adults, but more like they had a DH D. So again, we really do kind of stray away from making that diagnosis of bipolar disorder and communicating with patients discussing this emotional impulsivity, this quickness with which they experience emotions more likely is occurring in the setting of either an anxiety disorder or, or an A DH D disorder. Um when and I put in here a few studies for those that are interested in. Um but there are a few different um or so ways uh that this emotion disregulation occurs in um A DH D. So both from a bottom up control. So there's a lack of emotion regulation. There's challenges with orienting to an emotionally salient stimuli. Um they have trouble with evaluating like a reward. And so they have these preferences for short immediate rewards instead of being able to or to demonstrate that patients um they also have impairments in emotion uh labeling. And so there's this emotional misperception which is linked to these um to these or an aberrant emotional responses which then creates this uh whirlwind storm of um or a temper, tantrums, hot uh temper. However, you want to describe it. So again, this A DH D was associated with preference for these uh small um quick rewards over larger delayed ones. And so the evaluation of these emotions, he has been studied in relation to the evaluation of signals for potential reward. But then there's also this top down control where there is an ability to adjust their top down regulation and response to different emotional stimuli, partially which is partially a loss in individuals with a DH D. So they can't direct their attention towards or away from emotional stimuli. So as to maintain their or their homeostasis. So what does this course look like over time? So, you know, we can ii I mean, I see kiddos in my clinic where I have made the diagnosis even as young as the age of three. So the symptoms though especially um uh uh so for those that have predominantly the hyperactive can and are observed by the age of four. So preschool age and can increase the next three, four years, which peaks in the severity when a child is 7 to 8 years of age. But then after the, but then, but then after that, the hyperactive symptoms start to decline more. But the impulsive symptoms usually persist throughout life and the symptoms of inattention typically are not apparent until the child is eight to a nine years of age. So again, around that transitional age to a middle school, um and these symtoms of inattention are usually a lifelong problem. Uh That doesn't necessarily mean that it, that an individual has to be on treatment or on a medication for it. But um but challenges with executive of functioning attention based uh processes, um I'd like to talk a little bit about um because I often get this question or both from uh or, or, or both from primary care providers as well as particularly with patients. But um how does a DH D interact with substance use and how does a DH D treatment interact with substance use? So we know that a DH D at baseline uh significantly predicts the development of any substance use disorder. Um even when they control for ses uh for sex, for parental substance use disorder in these models. And so subjects with a DH D were um were about 1.5 times more likely to develop a substance use disorder. They were compared with controls. Um And so even when they had or have removed a lifetime history of chronic disorder. Um, um, so a DH D continued to be a significant risk factor for any drug use disorders as well as for cigarettes or smoking. Um, and so individuals with a DH D also had an earlier onset of substance use disorders compared with controls. And there was a, a significant interaction between a DH D uh status and set for cigarette smoking. Um, but I often tell people that when they've done studies that have um or that have tried to use or that I tried to look at when individuals with a DH D are, are on stimulant treatment. That actually the uh so the risk for any substance use disorder tends to either stay the same or come down in comparison to individuals with a DH D who aren't on any treatment. Um Now it doesn't necessarily come back down to or to or to the general population or to baseline. But to me, at least that makes me feel comfortable in prescribing kiddos with a DH D even in adolescence. Of course, I always talk about the development of substance use disorder in general and that's at an increased risk like, like this shows uh for having any type of substance use disorder and for smoking and for vaping. Um but that, but that then being on a treatment specifically on a treatment for a DH D is not going, is not going to increase that risk as far as the available data that we have and what were was shown to be helpful or predictive. So, as you can see here um amongst our subjects with a DH D comorbid um odd and kind disorder were significant predictors of substance use disorder while adjusting for sex and parental history of substance use disorder. But that actually extra help. Uh So for boys. So either through like a big brother, big sister or for or through any kind of peer, like a mentorship was shown to be protective against the development of any substance use disorder. Um, so I thought, so I talked, I talked with, I talked with, uh, or the parents and providers that there are things that we can do that are Orion medications and the medications are helpful in treating the core symptoms of or a DH D. But they're not everything and we'll get into the kind of, uh, the multifactorial treatment of A DH D. Um, uh, but, you know, as kids get older, I start to worry about these things, I start to worry about, uh, their propensity for getting into car accidents as, as they start driving. So these real, so these real world implications of A DH D. So let's get into the treatment options for a DH D and for operational defined disorder. Um, because oftentimes primary care providers are the individuals, um, who, uh, or who are capable of providing that first line treatment option. Um, I put up here um the chart. So really the first line treatments are two main classes of stimulants. Those are the amphetamine classes. Um So the amphetamine classes which uh and I have a few charts um up here, but there are different brand names including Adderall, Vich Vance, et cetera as well as and then there's the methylphenidate class of stimulus. So those are things like Concerta rhythm and Falkland and both have been shown to be about equally efficacious with extremely strong and very robust effects is just for a frame of like a reference. This effect size of one is or significantly stronger than the effect size for ssris for anxiety and for depressive disorders. So I always tell people that stimulants are actually the most effective treatment we have for anything in psychiatry. They work and they work well, especially for those core symptoms of A DH D like inattention and hyperactivity. Um The second line of options we have are also good. Um And we'll talk about why you might choose one or the other. But those include things like ad amoxin cloNIDine and or, and uh guac I put up here a QR code uh that takes you to um the following slides which I'm not gonna really spend a whole lot of time on other than just to show you that these exist. Um They are online free. I like these charts. I keep one in my office. I have no affiliation with this group but it's helpful for me because it shows all the different types of preparations um, of these A DC like medicines. Um, and even myself as a child psychiatrist that prescribes these all day. Um, I still get confused at times about what does, what it's also nice because then, um, it shows as you can see we have lots of different options about because I start to talk about kiddos. I mean, all of these have been shown to be or like they've never been head to head studies between these but that they differ in their time release mechanisms as well as for um for how these are administered. So there, as you can see, there's some which have to be swallowed whole, there's some that can be open and sprinkled in apple sauce or water. There's some that are now uh a liquid or chewable or can be orally dissolved in your mouth. So I'm not gonna spend a significant amount of time going through each and every one of these. These exist, I'm always happy. Um If you all ever have questions about these to shoot me an email um as well. Um But these exist both for the methylphenidates um as well as for the amphetamines. As you can see, there's also um a patch formulations. Um There's a lot of different kinds and I'm happy and, and the time we have for questions to go over any and all of these um the adverse effects of stimulant treatment are about the same. There have never been head of head studies that shown um one causes less appetite suppression than the other. The things I do consent to my parents and kiddos to um uh are that it can and the thing I see most is that it does decrease appetite specifically when during its peak effects. So around like a lunchtime appetite. So I do track their weight over time. Um We do know that it can lead to some poor growth. We're not sure why if that's a function of interacting with their or with or with their bones or if it's just a product of decreased appetite leading to less growth. Um but on average, they grow about a centimeter less which is about a half an inch. So I always tell people unless they want their child to be in the NBA or the W NBA or some other um profession where height might be a factor that's usually not a huge concern and it hasn't necessarily been like a replicated a lot. Like I said, the mechanism is unknown. Um It can exacerbate. I have good questions about ticks, the best evidence we have that it might exacerbate ticks in a population, kiddo with a DH D that are already um at increased risk or odds of having a tick disorder. Uh As far as we know, it doesn't cause ticks out of the blue. Um And then uh I put up here that it can, uh, kind of like a worsen their sleep. They can have like a rebound effects during the wearing off period. Um, uh, it can lead to psychosis in rare cases. So if, if, if this is an individual that already has a psychotic disorder, like schizophrenia, I wanna be sure that they're already on an antipsychotic medication, but it's not a contraindication for me. Um, and then I always bring up, especially with my kiddos that I'm seeing that are about to go to college or in high school. The risk for a diversion, there is a street value to a lot of these stimulants. Um And like I said, where I like, I, I do feel comfortable in putting uh teenagers on stimulants, but it would have to be very upfront with teenagers and college age kiddos. Um that or that or that it is a federal offense uh to, or to give people these like a medicines to uh or to sell these like uh um as well. So there is a very real risk that I talked to about uh with these patients. Um a quick word on the mechanism of action. Like I said, the stimulants tend to work about the same. When we look at clinical effects, they do work a little differently, which is why there is a preferential uh response. We're not at a stage in 2024 where we can accurately predict which ones um will work for which patient. However, both the amphetamines and the methylphenidates to enhance the impact of both uh dopamine and norepinephrine on the neurotrans transmission by blocking the reuptake of these transporters. The amphetamine classes work different than the methyl because in addition to that, they also increase the catecholamine release from the synaptic vesicles. So the therapeutic effects of stimulants on behavior and the attention broadly script are, are presumed to be, these are related or are presumed to be related to this enhanced neurotransmission of these catecholamines, especially in the prefrontal cortex. Um uh the or the amphetamines inhibit, like I said, the reuptake uh via both the membrane transporters and at higher concentration, these vesicular transporters. Whereas um uh the methylphenidate is about 40 to 70 fold less potent than D or than the de amet amine. Um oops sorry, whereas um the amphetamine, whereas sorry, whereas the methylphenidate is between 40 to 78 le uh fold less potent than the deet amines and inhibiting the vesicular accumulation of dopamine or norepinephrine, but is a similarly potent inhibitor of the snap degree of take of dopamine and slightly less potent for the norepinephrine. So again, not to stress it too much. But that is why people have different responses to a different kind of medicines. When they looked at these big, like a meta studies, uh there's potentially more of like a very slight increase in efficacy for the amphetamines but slightly more tolerability for the methylphenidates. Um I personally tend to choose the methylphenidate just because of that tolerability concern. Um But you're not wrong to start with Adderall, for example, with or with an amphetamine, for example, what about the non sim or medication options? So, um ad amoxin is a norepinephrine uh transporter um reuptake inhibitor. Um It does just so you are aware it has a or a metabolization through the liver through the or the CRE or the cytochrome P 452 D six, which is important because a lot of kiddos with A DC also have anxiety that might be on PROzac or FLUoxetine for example, which can inhibit um this particular enzyme. So it, it's less about the detail about which enzyme but just being aware that it can interact with other, with other of the medication that we commonly use within the role of psychiatry. Um It tends to be relatively well tolerated. It's nice because it tends to have less of um the sleep concerns, less of the appetite concerns. But I do see people with that amoxin who have a decreased appetite as well, it can increase their blood pressure. So I do track their blood pressure but it's usually only by a few points from when they look at the systolic blood pressures. There is a black box warning, like with any like medications in psychiatry that target the serotonin or the norepinephrine. We have take inhibitors of the suicidal behavior and then specifically for amoxin for the liver toxicity because it is metabolized through the liver that's never stopped me from prescribing these medicines. However, and then for Chloe and guanine, which are alpha two agonists, the clinical efficacy of guac clin and cloning is primarily attributable to this post synaptic alpha two agonist effects which result in enhanced um norepinephrine uh neurotransmission cloning those less specific for the alpha two A receptors and guine and binds to a variety of other receptors. So, patients may respond preferentially to one or the other that uh they are FDA proved to be prescribed with stimulants. And it's actually the extended release versions of both the clo and the gloom that are FDA approved. So um I often and so that's, and, and those go by trade name um in tive for the glo extended release as well as cape for the clodine extended release. The cloning tends to cause more of the sedation or the somnolence, but especially in kiddos with a DH D that might have sleep concerns. I will consider using cloning to help with their ability to uh uh sort of fall asleep at night. Um What about off label treatments for a DH D I put this in because you'll probably get this question just as much, if not more than I do as a child psychiatrists. Usually by the time they come to see me, um they're kind of committed to starting a medicine. Um I put this in here. And I personally had to do some research about this, but um it kind of confirmed what I have already been educating people that we don't have a lot information to support. A lot of kind of like the fad diets that um a lot of our patients tend to come in with that asking about either the polyunsaturated fatty acid supplementation or the, or the reduction or the elimination of artificial food color um or the few foods diet. So these were the and so I put up this or meta like analysis here which for the of you that are interested can go and take a look at it yourselves as well. My biggest takeaways are um again, that or that I never discourage people from using, but I tell them that they certainly aren't as effective as stimulants. Um And a lot of these diets have been shown to be more helpful in helping um uh to, to show individuals which foods to avoid or that they might get more activated or behaviorally activated on. Um But to me, I've never seen any convincing evidence that it, that all by itself, it can make a huge difference for a lot of the hyperactive or impulsive symptoms. You will have parents and families who do swear by these. And so again, I never tried to discourage parents or families from doing these as far as they can tell there's no real harm or like a negative effects, then the cost or the time that's associated with trying to go through this and the hassle. Um But, but I always kind of um tried to do my piece in educating that really the best treatments or the most proven treatments that we have, despite their drawbacks, there's no one perfect treatment are the stimu uh treatments. Now, there are also some neuro therapeutics for A DH D and I, I can imagine if I were to give this talk in five or 10 years, this slide might look very different, to be honest. So there is a lot of emerging evidence and research that's being done. None of it, in my opinion is ready for prime time to be done as first line treatments. But you, but you might have uh uh um or so individuals uh patients and their families that do ask you about these. Um And again, I emphasize that the most successful treatment is with psychostimulant medication which enhances catecholamines in the brain. Um But that there has been some studies that have started to come out about neurofeedback, which actually has been tested in a DC for about 45 years. So there are a large number of like a meta analysis of randomized control trials that show consistently small to a medium effect sizes for symptom improvements, but still of controversy regarding the or the blindness of the Raiders. So again, um I don't dissuade people from trying to get neurofeedback, there's a cost associated obviously with it. Um But I can't personally um advocate as a first line treatment. Um There's also individuals that are looking into T MS now, um which has been shown to be like a relatively safe, but based on conducted studies so far, there's relatively level evidence at this point in time, 2024 that uh or that T MS improves a DH ES symptoms or cognitions. Um There's so actually trigeminal nerve stimulation is now the only brain stimulation technique that is FDA proof for a DH D. However, that was based on rather or a limited um evidence. Um And again, there is a cost associated with it and this is a device that kiddos wear at night and if they're already struggle with sleep or with impulsivity, um pulling it off at night is my concern. Um But I have had one or two patients that have tried to go this route and then there are uh Digital Therapeutics, which is essentially a video game that has been FDA approved um which is and so this Endeavor Rx was the first FDA approved a game based digital therapeutic, approved for the treatment of pediatric A DH D. Um uh It is a game based uh Digital Therapeutic which improved an intention more than the control upon assessment by assessors. However, it also led to a lot of headaches. So again, I've had maybe one or two patients that have tried that. Um, but I always advocate to patients that, you know, if they're gonna do these, that I, um, I'm not opposed to that but that I would have, uh, uh, a rather, um, quick trigger to consider more uh proven um, options. Now, these are um, some non pharmacological treatments for a DH D that I always talk about with patients. I always tell patients that even though our are, or even though the simmons are effective, I really take the kind of the whole person into account. And so I do always advocate for um non medication treatments for the issue. So you just saw the last couple of slides, I don't necessarily uh prescribe those like a diet for example, but I always tell them that, that those types of diets exist out there that if they're interested, but that really a lot of kind of the other help or support that I offer for patients and their families are uh where we can help to support them in their everyday life and or their functioning. So that often includes like the social skill stuff. So not just for individuals with autism, but individuals with a DH D that have a lot of that impulsivity that might be helped by stimulants. I still advocate for things like social skills groups. I advocate for things like school based interventions through a 504 plan or through an IEP for example. Um and then PC which is child interactive therapy. Um A lot of the p data was actually done here at Mr was I was not involved with those studies. Um But as a parent myself, as well as a clinician, I can tell you that it's a program for, with 2 to 7. Uh sorry, I'm aged 2 to 7 year olds. Um and their parents or caregivers that aims to decrease Externalizing uh child behavior problems, increase positive parenting behaviors and improve the quality of parent, child relationship, which is often strained in kids with a DH D. So it's, it's uh so, so if individuals are looking for a therapy or a therapy option, especially before considering am medicine, I often will try to refer for PC it, for example. So to kind of end our last few slides, uh uh the title of my talk was Disruptive Impulse control and con disorders. Um So again, these or this category encompasses conditions involving problems in self control, emotions and their behaviors um which does have a male predominance and um a childhood onset. So here's just the criteria for odd. I personally, as a provider don't like to necessarily make the diagnosis of odd because I think it often gets misused um in non clinical or settings like school or, or like elsewhere that kind of puts the blame on the kiddo. Um But it does describe a constellation of symptoms, this pattern of angry and irritable mood or humanness and defiance or vindictiveness that lasts at least six months. An essential aspect of OED is this frequent and persistent pattern of irritable mood, argumentativeness and vindictiveness for. And um the symptoms of of odd may be confined to only one set. So it's most often at home though sometimes I often see it in teachers also. Uh it has a prevalence in the general population of about 1 to 10% 1 to 11. It does have a male predominance. Um It tends to appear during preschool years and often precedes the development of chic disorder but not everyone with led goes on to, to develop chronic disorder and conveys a risk for development of anxiety and for depressive disorders. Uh The defiance, argumentativeness, the vindictiveness symptoms uh carry the most of the risk for chronic disorder. Um and the angry irritable mood symptoms carry most of the risk for and or or for a major depressive disorder and for anxiety disorders. So, temperamental uh factors that are related to problems in emotion regulation, like poor frustration tolerance have also been predictive of odd as well as harsh and consistent or neglectful child rearing practices are common um in families of child and adolescent patients with um odd chronic disorder. On the other hand, really describes this persistent and per uh this persistent pattern of behavior in which the basic rights um uh or rules are violated. And they have to have at least three out of 15 criteria in the past 12 months and the, the kind of the big four criteria are aggression of people or animals, destruction of property deceitfulness or theft and serious violations of rules. Um I often see kiddos with kind disorder also have a DH D. So like we talked about comorbidity is certainly the rule childhood onset, certainly predicts a worse course. Um And again, those kiddos that have it less than the age of 10, most of them also have a DH D or other neurodevelopmental disorders. Um And finally, disruptive mood dysregulation disorder is actually not in the impulse control category of DS M, but it's actually in the Depressive disorder chapter of the DS M five. and it's important also that I point out that D MD D and odd cannot be diagnosed in the same individual, but D MD D uh really uh was a new diagnosis that was introduced in this DS M five which came out in about 2015 as an attempt to, to help to or to reduce the rate of childhood um childhood or bipolar diagnosis, which would then uh or, or see a lot of kiddos being put on things like antipsychotics or, or lithium. So it helps to describe these kids that have these severe and recurrent temper outbursts which are inconsistent with their developmental level, but happen very often. Um and the interval mood in between is predominantly um irritable and is observable by others. So kind of um how do we piece all this together? So, um uh, so when I'm trying to decide is this odd kind of disorder? D MD D A DH D? So again, we know that um, individuals, um uh, with or so with both conor and odd are related to symptoms that bring the individual in conflict with adults and other authority figures like parents, teachers or work, work supervisors. But the behaviors of odd are typically of a less severe nature than those of individuals with con disorder. Um And odd has more of this angry and irritable mood and argumentativeness. Whereas kind disorder is really this kind of like rule violation and um kind of a destruction of property. Uh uh or so that I see, whereas uh D MD D is, you can see the difference uh where D MD D is different than odd is really this like verbal and physical aggression towards themselves or towards other people. So what are the treatment of disruptive behavior disorders and aggression? Oftentimes you will be referring these individuals to a child and adolescent psychiatrist, but a lot of it, um a lot of the evidence really does suggest for non medication interventions. So again, um the psychoeducation of these disorders as well as behavioral interventions like C BT can be done for a disorders as well as parent management training. Um we and I want to emphasize this, that the psychopharmacology is used as a second line and there's relatively a weaker evidence base. Um, and, and all of this would be off label. I, I want to be clear about that but, but other agents that have been used are things like CL so a lot of the things that, that we saw used for a DH D so things like, um, Alpha Two Agnes like CLO, um, there has been some studies that have looked at a risperiDONE or ARIPiprazole which are antipsychotic medications. Oftentimes if you're doing this, you're probably doing it in conjunction with a child psychiatrist. Um and, and various or or severe cases. I have put um individuals with con disorder on or on a dose of it or lithium to help. And there has been uh a few studies that have shown that that has been helpful, but really for chronic disorder, um the where the evidence based treatment is a nonmedication treatment called multisystem therapy um which which really tries to help the individual in the community with law enforcement, with parents, with school. So before I turn it over to questions, a few concluding thoughts. So again, the long history is very important to screen for psychiatric comorbidities. Oftentimes in child and adolescent psychiatric comorbidity is the rule um that really the psycho stimulants are effective at treating these core symptoms of DH D. Um And that the behavioral interventions we have including various behavioral therapies can provide additional benefit above and beyond, especially for those kiddos with irritability and challenges with uh parents or caregivers as well. So I really appreciate you all being on today. Um And for your question. So. Created by Presenters Max Rosen, MD Child and Adolescent Psychiatrist View full profile
