Attention Deficit Hyperactivity Disorder

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• Attention Deficit Hyperactivity Disorder

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• Anne Marie McCarthy, MD
• February 19, 2009

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Outline of Lecture

• Definition of ADHD
• Prevalence
• Pathogenesis
• Clinical Features
• Evaluation and Diagnosis
• Common Co-morbid disorders
• Treatment Options
• Prognosis

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My View of Developmental Concerns

• Children want to succeed and please adults
• No child chooses to be in trouble all the time
• If they could do it they would
• Were asking them to do something they cant
• He did it last week
• If they arent succeeding, Its the adults
  responsibility to put them in an environment
  where they can succeed

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Definition of ADHD

• Attention-deficit/Hyperactivity disorder
• Manifests early in childhood
• Symptoms of hyperactivity, impulsivity and/or
  Inattention
• 3 to 10 of children are diagnosed w/ ADHD
• One third to two thirds of those children have
  symptoms that persist into adulthood.
• 1 to 6 of general Population

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Why Do We Care

• The symptoms affect
• Cognitive, academic, behavioral, emotional and
  social functioning
• Have lower academic and occupational performance
• Increased risk for Social and Financial
  instability
• Increased risk for injury and MVA

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Prevalence
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Prevalence

• Overall Prevalence in children, 2 to 16
• Differences in estimates accredited mostly to
  population studied (Primary care vs Referral)
• One of most common childhood disorders
• Prevalence estimate of school aged children
• 8 to 10
• Approximately 4.4 million US children

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Prevalence

• Gender Differences
• Prevalence boys, 11
• Prevalence girls, 4.4
• Prevalence increases w/ increasing age
• 4.1 for children lt 9 yrs old
• 9.7 for children gt 9 yrs old

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Pathogenesis
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Pathogenesis

• Major Theory - Genetic Imbalance in Catecholamine
  Metabolism in Cerebral Cortex
• Global structural brain imaging differences
• caudate nucleus, cerebral and cerebellar volume,
  smaller posterior corpus callosum regions.
• Functional brain imaging differences
• ADHD brains have reduced global activation
• Reduced local activation of frontal lobe

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Pathogenesis

• Genetic Imbalance in Catecholamine Metabolism
• Genetic Basis for the theory is supported by twin
  studies
• As high as 92 concordance for monozygotic twins.
• 33 concordance for dizygotic twins
• Studies have identified a number of genes that
  appear to play a role in the development of ADHD

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Pathogenesis

• Genetic Imbalance in Catecholamine Metabolism
• Catecholamines - Dopamine, Nor-epinephrine, and
  Epinephrine
• Dopamine and Nor-epinephrine are major
  Neuro-modulators in the CNS, (neurotransmitters)
• Research suggests a Genetic imbalance b/w
  Nor-epinephrine and dopamine systems
• Dopaminergic activity decreased and Nor-epi
  increased

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Pathogenesis

• ADHD theory is a deficit in Dopamine
• Dopamine tied to
• attention,
• alertness,
• vigilance,
• executive function (abstract reasoning, mental
  flexibility, planning and working memory)
• increased goal directed behavior,
• control of flow of information from different
  areas of the brain.

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Pathogenesis

• Dopamine disorders cause decline in
  Neuro-cognitive functions
• especially memory,
• attention
• problem solving.

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Clinical Features
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Clinical Features

• Three Categories of Symptoms
• Hyperactive
• Impulsivity
• Inattention
• Depending on predominant symptoms, three subtypes
  of ADHD have been identified
• Combined Type (ADHD-C)
• Hyperactive-Impulsive type (ADHD-HI)
• Inattentive type (ADHD-I)

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Clinical Features

• ADHD C (Combined type)
• Classic type that is seen most commonly
• Diagnosed 6 yrs to 7 yrs old
• ADHD HI (Hyperactive-Impulsive)
• Diagnosed 6yrs to 7yrs old,
• Cant inhibit behavior, cognitive performance
  less likely to be affected
• ADHD I (Inattentive)
• Diagnosed 9 yrs to 10 yrs olds (more academically
  challenging age range)
• FemalegtMale

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Clinical Features

• Hyperactive
• Excessive fidgetiness or talking
• Cant remain seated
• Cant play quietly,
• runs or climbs excessively or talks excessively
• Always On the Go restlessness
• Usually present by 4 yrs old
• Peak 7 to 8 yrs old
• Usually barely discernible by adolescent yrs

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Clinical Features

• Impulsive -almost always occurs w/ hyperactive
• Difficult waiting turns
• Blurting out
• Disruptive
• Intruding, interrupting others
• Peer rejection
• Unintentional Injury to self or others
• Present by 4yrs old , Peak 7 yrs to 8 yrs old
• Usually persist into adulthood

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Clinical Features

• Inattention
• Forgetfulness
• Easily distracted, Does not seem to listen
• Losing or misplacing things
• Disorganization
• Academic underachievement
• Difficulty sustaining or poor follow-through w/
  tasks,
• Poor concentration
• Poor attention to detail
• Present 8 yrs to 9yrs old
• Persists into adulthood

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Evaluation and Diagnosis
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• Attention-Deficit/Hyperactivity Disorder (ADHD)
• When problems with attention, hyperactivity, and
  impulsiveness develop in childhood and persist,
  in some cases into adulthood, this mental
  disorder may be diagnosed.
• Diagnostic criteria for Attention-Deficit/Hyperact
  ivity Disorder(cautionary statement)  
• A. Either (1) or (2) (1) inattention six (or
  more) of the following symptoms of inattention
  have persisted for at least 6 months to a degree
  that is maladaptive and inconsistent with
  developmental level (a) often fails to give
  close attention to details or makes careless
  mistakes in schoolwork, work, or other
  activities (b) often has difficulty sustaining
  attention in tasks or play activities (c) often
  does not seem to listen when spoken to
  directly (d) often does not follow through on
  instructions and fails to finish school work,
  chores, or duties in the workplace (not due to
  oppositional behavior or failure to understand
  instructions) (e) often has difficulty
  organizing tasks and activities (f) often
  avoids, dislikes, or is reluctant to engage in
  tasks that require sustained mental effort (such
  as schoolwork or homework) (g) often loses
  things necessary for tasks or activities (e.g.,
  toys, school assignments, pencils, books, or
  tools) (h) is often easily distracted by
  extraneous stimuli (i) is often forgetful in
  daily activities 
• (2) hyperactivity-impulsivity six (or more) of
  the following symptoms of hyperactivity-impulsivit
  y have persisted for at least 6 months to a
  degree that is maladaptive and inconsistent with
  developmental level
• Hyperactivity (a) often fidgets with hands or
  feet or squirms in seat (b) often leaves seat in
  classroom or in other situations in which
  remaining seated is expected (c) often runs
  about or climbs excessively in situations in
  which it is inappropriate (in adolescents or
  adults, may be limited to subjective feelings of
  restlessness) (d) often has difficulty playing
  or engaging in leisure activities quietly (e) is
  often "on the go" or often acts as if "driven by
  a motor" (f) often talks excessively
• Impulsivity(g) often blurts out answers before
  questions have been completed (h) often has
  difficulty awaiting turn (i) often interrupts or
  intrudes on others (e.g., butts into
  conversations or games) 
• B. Some hyperactive-impulsive or inattentive
  symptoms that caused impairment were present
  before age 7 years. 
• C. Some impairment from the symptoms is present
  in two or more settings (e.g., at school or
  work and at home). 
• D. There must be clear evidence of clinically
  significant impairment in social, academic, or
  occupational functioning. 
• E. The symptoms do not occur exclusively during
  the course of a Pervasive Developmental Disorder,
  Schizophrenia, or other Psychotic Disorder and
  are not better accounted for by another mental
  disorder (e.g., Mood Disorder, Anxiety Disorder,
  Dissociative Disorders, or a Personality
  Disorder). 
• Code based on type 
• 314.01 Attention-Deficit/Hyperactivity Disorder,
  Combined Type if both Criteria A1 and A2 are met
  for the past 6 months 314.00 Attention-Deficit/Hy
  peractivity Disorder, Predominantly Inattentive
  Type if Criterion A1 is met but Criterion A2 is
  not met for the past 6 months314.01
  Attention-Deficit/Hyperactivity Disorder,
  Predominantly Hyperactive-Impulsive Type if
  Criterion A2 is met but Criterion A1 is not met
  for the past 6 months Coding note For
  individuals (especially adolescents and adults)
  who currently have symptoms that no longer meet
  full criteria, "In Partial Remission" should be
  specified.
• Also ADD, ADHD, hyperkinetic child syndrome,
  hyperkinetic reaction of childhood, minimal brain
  damage, minimal cerebral dysfunction, minor
  cerebral dysfunction
• Moss, Deborah Shelly the Hyperactive Turtle
  1989
• Quinn, Patricia Putting on the Brakes Young
  People's Guide to Understanding Attention Deficit
  Hyperactivity Disorder 1992
• nostic Criteria - DSM-IV table

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Evaluation and Diagnosis

• Things to Emphasize w/ DSM-IV Criteria
• Symptoms must be present in more than one setting
• Must persist gt6mo
• Must be present before 7 yrs old
• Must impair function in academic, social or
  occupational activities
• Must be excessive for developmental level of
  child
• Another diagnosis cant account for symptoms

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Evaluation and Diagnosis

• Evaluation should include Medical, Developmental,
  Educational and Psychological Evaluation
• Information gathered from the patient, parents,
  teachers, any other available care givers.
• Teachers are a major source of referrals for
  evaluation.

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Evaluation and Diagnosis

• Tools exist for rating core behaviors and
  determining degree of functional impairment.
• Two types of behavior rating scales have been
  developed
• Narrowband scales, aka ADHD specific scales
• Focus directly on ADHD
• Sensitivity and Specificity gt90
• Broadband scales
• Assess ADHD and other behaviors
• Less sensitive and specific

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Evaluation and Diagnosis

• Age of diagnosis
• Diagnosing younger than 6 yrs old is difficult,
  BUT
• 79 of those that met criteria at age 4 to 6
  continued to meet criteria three years later.
• Subtypes can change over the course of time in an
  individual

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Differential Diagnosis
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Differential Diagnosis

• Learning Disabilities
• Behavior and Emotional Problems
• Depression, Bi-polar, Anxiety, PTSD,
• Mental Retardation
• Fragile X
• Environmental Factors
• Stressful home, Inappropriate school setting
• Hearing or Visual Impairment
• Asthma
• Fetal Alcohol Syndrome
• Thyroid Abnormalities
• Sleep Disorders
• Seizure Disorders

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Differential Diagnosis

• Hint to diagnosis
• Symptoms persistent and pervasive
• Should be re-evaluated for wrong diagnosis if
• Symptoms worsen
• New symptoms occur
• Not responding to treatment

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Co-morbid Disorders
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Co-morbid Disorders

• As many as ½ of the children diagnosed w/ ADHD
  have one or more co-morbid conditions
• Oppositional Defiant Disorder
• Conduct Disorder
• Depression
• Anxiety, Tics, OCD
• Learning Disabilities

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Co-morbid Disorders

• Oppositional Defiant Disorder (ODD)
• Negativistic, defiant, disobedient and hostile
  toward authority plus four of the following
• Often loses temper
• Often argues w/ adults
• Often actively defies or refused to comply w/
  requests
• Often deliberately annoys people
• Often blames others for his/her mistakes
• Often touchy or easily annoyed by others
• Often angry or resentful
• Often spiteful or vindictive

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Co-morbid Disorders

• Oppositional Defiant Disorder (ODD)
• Coexists w/ ADHD up to 35 of cases
• More common in ADHD-HI type
• If have ADHD-C or ADHD-HI, are at risk of
  developing ODD
• ADHD frequently puts them in conflict w/ adults
• Conflict leads to more discipline and less
  positive reinforcement

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Co-morbid Disorders

• Conduct Disorder
• Repetitive and persistent pattern of behavior in
  which the basic rights of others or major
  societal norms are violated.
• Additional symptoms
• Aggression to people and animals
• Destruction of property
• Deceitfulness or theft
• Serious rule violations

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Co-morbid Disorders

• Conduct Disorder
• Co-exists w/ ADHD up to 26 of cases
• Appears more commonly in ADHD-C and ADHD-HI
• Depression
• Co-exists w/ ADHD up to 18 of cases
• Occurs more commonly in ADHD-C and ADHD-I
• Likely to have family hx of depression
• During adolescence, increase risk for suicide
  attempt

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Co-morbid Disorders

• Anxiety Disorder
• Co-exists w/ ADHD up to 26 of cases
• More common in ADHD-I
• Criteria include excessive anxiety and worry,
  about several different events or activities
  which is difficult for child to control plus at
  least one of
• Restlessness
• Easy fatigability
• Difficulty concentrating
• Irritability
• Muscle Tension
• Sleep Disturbance

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Co-morbid Disorders

• Learning Disabilities
• Data regarding rates of co-existence of specific
  types of learning disabilities and ADHD are
  lacking
• Estimates of coexistence ranges from 20 to 60
• Hard to tell, does the ADHD lead to the
  scholastic delay defined as learning disabilities
• Or does learning disabilities lead to behavior
  that meets criteria for ADHD
• Learning Disabilities occur more commonly among
  ADHD-C and ADHD-I

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Co-morbid Disorders

• Learning Disabilities
• Neuropsychologic testing
• May help clarify diagnosis and identifying
  strengths and weaknesses
• Children w/ Learning, Language, visual-motor and
  auditory processing problems usually perform
  poorly only in their particular problem area
• Children w/ ADHD usually perform poorly in
  several areas of evaluation

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TreatmenT
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Treatment Options

• Treatment may involve the following alone or in
  Combiation
• Medication
• Behavioral/Psychologic Interventions
• Educational Interventions
• Decisions should involve patient and parent
• Weigh risks and benefits of all options

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Treatment - General Principles

• Managed as the chronic condition that it is
• Specific treatment goals should be set
• Regularly monitor effectiveness of interventions
• PCP should be information sources
• Referral to Specialist if
• Younger than six
• Co-morbid psychiatric conditons (ODD, CD,
  substance abuse, emotional problems)
• Co-morbid medical conditions (sz, PDD)
• Lack of response to treatment

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Treatment - General Principles

• Management should include setting achievable
  goals
• Sample Target Outcomes
• Improved peer relations
• Improved academic performance
• Improved rule following
• If goals cant be achieved, should evaluate
  original diagnosis, undiagnosed co-morbid
  conditions and/or treatment compliance

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Treatment - MedicATION
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Medication

• Approximately 56 of those diagnosed are treated
  w/ medications
• At least 80 of properly diagnosed children will
  respond to one of the available stimulants if
  they are tried in a systematic way
• Have significant clinical effect on hyperactivity
  scales
• If fail to respond or experience intolerable side
  effects on one stimulant, other available options
  should be tried

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Medication

• Stimulants are first-line treatment
• Why would I stimulate a child that cant sit
  still
• Stimulants increase the amount of dopamine
• Dopamine is an inhibitory force
• Youre stimulating an inhibitor
• Youre making the brakes work better.

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Medication

• ADHD brains have increased number of dopamine
  transporters which clear dopamine from the
  synapse (extracellular area) too quickly.
• Medication increases extracellular dopamine in
  the brain
• Dopamine re-uptake inhibitor
• Dopamine has inhibitory activity
• Medication (a stimulant) is stimulating an
  inhibitor

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Neurotransmitter cell signaling

• Reuptake Inhibitors

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Medication

• Two main classes of drugs Methylphenidate and
  Amphetamines
• Affect dopaminergic and noradrenergic systems
• No demonstrated difference if efficacy b/w
  classes
• Have different formulations w/ different release
  preparations (short acting vs long acting)
• Differences are individually based
• Tolerance (If side effects w/ one, should try
  the other)
• Effectiveness (meeting behavioral needs?,
  addressing symptoms?)

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Medication

• Side Effects Safety established over 50yrs of
  use
• Effects are reversible, (long term side effects
  and drug dependence do no occur)
• Similar b/w the two main classes
• Occur more commonly if used in preschool years
• Anorexia or appetite disturbance (80)
• Sleep disturbance (3 to 85)
• Weight Loss (10 to 15)
• Deceleration of linear growth (Adult height not
  affected)
• Less Common Side Effects
• Increased hrt rate or BP, HA, stomach ache
• Social withdrawal, nervousness, irritability,
  moodiness

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Behavioral Interventions

• Modifications in Physical and Social Environment
  (environmental modification)
• Has not been shown to significantly reduce core
  symptoms
• Can improve behavioral problems
• Center around consistent rewards and consequences
  depending upon whether specific goals were met

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Behavioral Interventions

• Helpful Strategies
• Maintaining a daily schedule
• Minimizing Distractions
• Helping w/ organization of possessions
• Setting small, reachable goals
• Rewarding positive behavior
• Using visual cues (charts, checklist) to stay on
  task
• Limiting Choices
• Finding activities that the child will be
  successful
• Using calm discipline techniques (time-out,
  removal, distraction)

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Psychosocial therapies

• Behavioral Modification Techniques
• Cognitive Therapy
• Play therapy
• Designed to change childs emotional status
• Work best if other co-existing psychologic
  condition
• Little documented efficacy in tx of core symptoms
• But, significant improvement of overall quality
  of life for child and family if stressors or
  co-existing conditions exist

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Educational Interventions

• May require changes in educational programming
• Tutoring
• Resource Room support
• Classroom modifications
• Assignments written on the board
• Sitting next to teacher
• Extended time to complete tasks
• Private signal from teacher if off task
• Completion of daily report card (monitor
  symptoms)

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Educational Interventions

• ADHD qualifies as a disability under IDEA
• Individuals w/ Disabilities Education Act
• ADHD may qualify for special education services
• Or may qualify for accommodations under Section
  504 of the Rehabilitation Act
• Americans w/ Disabilities Act
• Provide reasonable accommodations in private
  schools (secular) and post- secondary education

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Alternative Therapies

• Some common Alternative therapies
• Vision training
• Special diets (avoidance of sugar, allergens or
  food additives)
• Megavitamins
• Herbal and mineral supplements
• EEG biofeedback
• Applied Kinesiology

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Alternative Therapies

• Being used in as high as 68 of ADHD pts
• Benefits have not been demonstrated in double
  blind , randomized controlled trials
• Risks include potential failure and setback for
  child when symptoms persist and unnecessary
  expenses

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Comparing Treatment Options

• Stimulant Therapy versus Multimodal Therapy
• Assigned 600 children b/w 7 and 9.9 yrs old to
  four different groups
• Medication management (Stimulant tx)
• Behavioral Treatment (Parenting training,
  child-focused tx and school-based intervention)
• Combined Treatment (combination of the two above)
• Community care (Initial assessment explained,
  list of community mental health resources and tx
  as prescribed by their own provider)

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Comparing Treatment Options

• ADHD symptoms improved in all groups over time
• Combined was not more effective than in reducing
  core symptoms than meds alone
• If received meds, w/ or w/out behavioral tx,
  showed gt improvement than those w/ behavioral tx
  or community care w/out meds.
• Behavioral tx w/out meds was similar to community
  care w/out meds.
• Combined tx improved symptoms like
  oppositional/aggressive, social skills,
  parent-child relations and reading achievement
  the most

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Prognosis
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Prognosis

• The symptoms affect
• Cognitive, academic, behavioral, emotional and
  social functioning
• Impaired Academic Functioning
• Completion of less schooling
• Lower achievement scores
• Failure of more courses
• Finding persist even if dont still meet ADHD
  criteria
• Employment
• Lower status jobs
• Poor performance compared to controls

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Prognosis

• Antisocial Behavior
• Increased risk for Antisocial Personality
  Disorders
• 12 to 23 chance if ADHD-HI vs 2 to 3 chance
  in controls
• Risk appears independent of co-morbid CD
• 54 arrested by 21yrs old vs 37 of controls

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Prognosis

• Substance Abuse during Adolescense
• Data unclear, some say increased risk, some dont
• Increased prevalence if co-morbid condition
• Those who receive pharmacotherapy tx, have almost
  2 fold reduction in substance abuse.
• Injuries
• Increased incidence of intentional and
  unintentional injuries

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Prognosis

• Driving
• ADHD individuals are 2 to 4 times more likely to
  have MVA than those w/out ADHD
• Also more likely to have license suspended
• Driving performance improves w/ stimulant tx

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Conclusion

• ADHD is a prevalent, pervasive disorder that
  affects cognitive, academic, behavioral,
  emotional and social functioning.
• Diagnosis and treatment can improve functioning
  in most of the affected areas.
• No child wants to be in trouble all the time.
  Theyre doing the best that they can. Its up to
  us to help them succeed.

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References

• ADHD, A Complete and Authoritative Guide,
  American Academy of Pediatrics,2004 Reiff, M,
  Tippins,
• The National Initiative of Childrens Healthcare
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• Clinical practice guideline diagnosis and
  evaluation of the child with attention-deficit/hyp
  eractivity disorder. American Academy of
  Pediatrics. Pediatrics 2000 1051158
• Evaluation and Diagnosis of ADHD in Children,
  Up-to-Date version 16.3, December 5, 2007
• Overview of the Treatment and Prognosis of ADHD
  in Children, Up-to-Date version 16.3, June 18,
  2008
• Pharmacotherapy for ADHD in Children and
  Adolescents, Up-to-Date version16.3, September 6,
  2008
• Understanding ADHD. Information for parents about
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  American Academy of Pediatrics, Elk Grove
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