Adolescent ADHD

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Adolescent ADHD

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Etiology

• ADHD is a heterogeneous behavioral disorder with
  multiple possible etiologies
• Neuroanatomic/ Neurochemical
• CNS Insults
• Genetic Origins
• Environmental factors

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Core Symptoms Areas
Inattention
Impulsivity/Hyperactivity
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DSM-IV CriteriaInattentionSix or more of the
followingmanifested often

• Inattention to details/
• makes careless mistakes
• Difficulty sustaining attention
• Seems not to listen
• Fails to finish tasks

• Difficulty organization
• Avoids tasks requiring sustained attention
• Loses things
• Easily distracted
• Forgetful

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ADHD DSM-IV CriteriaImpulsivity/HyperactivitySi
x or more of the following-manifested often

• Impulsivity
• Blurts out answer before questions is finished
• Difficulty awaiting turn
• Interrupts or intrudes on others

• Hyperactivity
• Fidgets
• Unable to stay seated
• Inappropriate running/climbing (restlessness)
• Difficulty in engaging in leisure activities
  quietly
• On the go
• Talks excessively

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Variation in symptoms

• Symptoms vary in
• Pervasiveness
• Frequency of occurrence
• Degree of impairment

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DSM-IV Diagnosis Criteria

• Symptom criteria must be met for past 6 months
• Some symptoms must be present before 7 years of
  age
• Some impairment from symptoms must be present in
  2 or more settings
• The symptoms lead to significant impairment
• Symptoms are not exclusively due to other mental
  disorders

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DSM-IV Subtypes

• ADHD Predominantly Inattentive Type
• Criteria met for Inattentive but note for
  impulsivity/hyperactivity
• ADHD Predominantly Hyperactivity/Impulsivity Type
• Criteria met for impulsivity/hyperactivity but
  not for Inattention
• ADHD Combined Type
• Criteria are met for both inattention and
  impulsivity/hyperactivity

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Impact and cost of ADHD

• ADHD in adult prison inmates25
• More drivers with ADHD
• Drove without a license
• Had license revoked or suspended
• Had multiple crashes(2)
• Had multiple traffic citations(3)
• Subgroups of ADHD with comorbid ODD/CD were at
  highest risk

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Impact and cost of ADHD

• Despite similar educational levels and IQ scores,
  individuals with ADHD not taking medication
  display significantly more academic problems in
  school (25 repeat a grade) and lower occupation
  attainment

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Impact and cost of ADHD

• Parents of children with ADHD experience higher
  level of stress, self blame, social isolation,
  depression and marital discord
• 63 of 144 caregivers after diagnosis of child s
  ADHD changed work status

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• Laufer (1962) The behavior picture described
  tends to disappear with maturation, anywhere
  between twelve and eighteen years of age.
• Mendelson et al (1971) Our findings suggest
  that hyperactive children are generally behaving
  in a more normal way by the time they enter their
  teens
• Wender (1995)the past decade researchers have
  become convinced thatADHD is a common
  psychiatric disorder in adults
• Gadow and Weiss (2001) the validity of this
  disorder is now beyond controversy.

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Diagnosis of Adolescent ADHD

• Still an observational diagnosis
• DSM-IV criteria thought threshold could be too
  high
• Likely 4/9 (Barkley et al., 2001)
• Shouldnt apply age 7 criteria (Applegate et al.,
  1996)
• Semi-structured interview should be done
• Measurement of impairment

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Pitfall in the diagnosis of adolescent ADHD --I

• Individuals (esp. girls) who tend to exhibit
  fewer hyperactive symptoms
• Individuals who exhibit mental rather than
  physical restlessness
• The ubiquity of inattentive and impulsive
  behavior in normal adolescent life
• Developmental relativity, age appropriateness

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Pitfall in the diagnosis of adolescent ADHD --II

• Self report Vs parental report
• Difficulty to obtain data from secondary school
  teacher
• Uncooperative adolescents
• Multiple comorbid disorder
• Shared features of other adolescent onset
  psychiatric disorders
• Life span with multiple stresses

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Pitfall in the diagnosis of adolescent ADHD --III

• The uncertain validity of applying DSM-IV
  diagnostic criteria for ADHD in adolescent
• The difficulty of establishing impairment in
  functioning due to ADHD for adolescent
• Different definition of remission
• Syndromatic remission
• Symptomatic remission
• Functional remission

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Definition of ADHD Remission
lt8.0 ADHD symptoms lt4.5 ADHD symptoms GAFgt65
Syndromatic
Symptomatic
Functional
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Adolescent and adult with ADHDBackground

• A source of controversy and uncertainty in ADHD
  is the marked differences that have been observed
  in male to female ration between pediatric and
  adolescent samples
• Gender ration in pediatric sample heavily favors
  male 41 91
• Adolescent and adult samples have a more even
  gender distribution
• Differences in gender representation have
  threaten the validity of the diagnosis of
  Adolescent and adult ADHD

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Adolescent and adult with ADHDBackground

• Similar pattern of comorbidity had been
  documented in boys and girls with ADHD
• However, boys havegt2 fold increased rates of
  disruptive behavior disorder
• Disruptive behavior disorders drive clinical
  referrals of children but not adults

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Follow up studies in ADHD

• Montreal study by Weiss and Hechtman (1993)
• New York Study by Mannuzza,Klein et al (1998)
• Swedish Study by Rasmussen and Gillberg (2001)
• Milwaukee Study by Barkley (2002)

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What predicts persistence of ADHD into
adolescence?(Biederman, Farone et al1996)

• Familiarity of the ADHD(OR 2)
• Presence of psychiatry comorbidity (conduct
  disorder, mood or anxiety disorder) (OR 3)
• Family adversity (paternal mental illness,
  conflict in family) (OR 7)(plt0.001)

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Adolescent outcome

• decline in hyperactivity, improvement in
  attention span and impulse control (Hart, Lahey,
  Loeber, Applegate Frick, 1995)
• 30-80 of ADHD children continue to display
  symptoms in adolescence (Gittelman, Mannuzza,
  1985 Barkley, Fischer et al, 1990)
• 25-45 display oppositional or antisocial
  behavior or CD (Biederman, Faraone et al 1996,
  Biederman et al 1997)

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How are ADHD adolescents doing in school?

• 29.3 retained in a grade, 46.3 had been
  suspended, 10 dropped out.(Barkley,
  Fischer,1990)
• ADHD adolescents had more academic
  impairments(compared to baseline), lower IQ and
  mathematics achievement scores and more learning
  disabilities.
• Fail to work independently well
• Poor organization and planning
• Poor time management
• Poor follow through

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Differential diagnosis of ADHD--comorbidity
alter the clinical presentation and may require
multiple treatment

• Coexisting conditions
• Conduct disorder
• Learning disorder
• Oppositional defiant disorder
• Bipolar affective disorder
• Epilepsy
• Tourette syndrome

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Comorbid disorders in ADHD adolescents

• High percentage of antisocial behavior, but low
  rates of mood and anxiety disorders.(Weiss 1993
  Mannuzza 1991)
• 59 of ADHD adolescents had ODD, 43 had
  CD(Barkley,1990)
• Baseline comorbid CD significantly increase the
  risk for CD and ODD, Bipolar Disorder and alcohol
  and drug dependence on follow up.
• Baseline comorbid major depression increased the
  risk for ODD, Major Depression, Bipolar Disorder
  and Agoraphobia.
• Multiple anxiety disorder at baseline increased
  the risk for Anxiety Disorder.
• Youngster with non-comorbid ADHD had an increased
  risk for ODD, Tic Disorder, and Language
  disorder. (Biederman, Faraone et al, 1996)

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Comorbidity of adolescent ADHD
comorbidity Prevalence among ADHD adolescents Prevalence in general population
Academic impairment 20- 60 5 -15
Major depression 9- 32 3-5
Anxiety disorders 10- 40 3- 10
Conduct disorder 20- 56 unknown
ODD 20- 67 2 -16
Bipolar 6 -10 3 -4
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Overlapping Diagnostic Criteria
ADHD GAD Mania Depression CD/ODD
Restlessness
Poor attention
Increased activity
Distractibility
Irritability
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Psychiatry and Medical Disorders can mimic ADHD

• Mood Disorder
• Psychotic Disorder
• Adjustment Disorder
• Anxiety Disorder
• Learning/language Disorder
• Stress-related Disorder
• Developmental Disorder

• Sleep Apnea
• Substance Use Disorder
• Use of Other medications
• Seizure Disorder
• Vision problem
• Hearing Impairment

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How does having ADHD affect self esteem?

• ADHD individuals displayed lower self-esteem and
  psychosocial adjustment by adolescents and lower
  educational achievement and occupational status.
  (Mannuzza, Klein,1995)
• Lowered self esteem is part of the longitudinal
  outcome of ADHD

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How are ADHD adolescents getting along with their
families?

• Parent-adolescent relationship between ADHD
  teenagers and their parents are generally
  characterized by increased conflict, negative
  communication, distorted beliefs, and more
  disengagement, especially when the adolescents
  are diagnosed with ADHDODD.

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Adolescent ADHD and substance use

• Persistence of ADHD symptoms, family history and
  comorbid CD high prediction of drunkenness and
  daily smoking
• Among different symptom cluster in ADHD,
  inattentiveness is most predictive of substance
  use

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ADHD studies
Developmental outcome studies Developmental course studies
Diagnostic retention studies
Symptom trajectory studies
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Developmental outcome and developmental course
research

• Developmental outcome studyidentifying a cohort
  of children that meet diagnostic criteria for
  ADHD and follow them prospectively to determine
  whether they are at increased risk for any number
  of negative developmental outcome
• Developmental course study whether the symptoms
  of ADHD persist into adolescent

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Developmental outcome studies

• Thorley (1984)Childhood hyperactivity was
  associated with an increased risk for PD,
  antisocial behavior, peer relationship,
  educational difficulties,as well as continued HIA
  symptoms
• Clampit and Pirkle (1983) psychostimulants maybe
  effective in ADHD adolescents
• Barkley et al (1993) children with ADHD are at
  increased risk for a variety of negative
  developmental outcome in adolescence and
  adulthood.
• Barkley et al (2002) the educational,
  occupational, and psychosocial risks are
  associated with a childhood diagnosis of ADHD
  relative to both normal and clinical control
  populations.

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Limitations of developmental outcome studies

• It remains unclear whether
• ADHD symptomatology may interfere with normal
  development process, including parent-child
  relationships, peer relationship and/or academic
  performance that in turns increase the risk of
  negative outcome, or
• ADHD may facilitate the onset and persistence of
  other behaviors/psychiatric disorder that
  increase the risk for negative outcome.

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The importance of developmental course study

• Clarify the mechanism linking childhood ADHD to
  later negative developmental outcome
• An improved understanding of the developmental
  course of ADHD symptomatology would provide
  information for the construction of
  developmentally sensitive diagnostic criteria

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Developmental course studies

• Diagnostic retention studies
• Symptom trajectory studies
• MacCallum et al (2002) repeated measures data
  of a continuous variable provide more information
  than a dichotomous diagnosis

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Diagnostic retention studies

• Hill and Schoener (1996)meta-analysis of 9
  diagnostic retention studies. Rate of ADHD
  desisted by 50 every 5 years(beginning at 9)
• Barkley(1998)s criticize 1. Many of the studies
  included were initiated prior to the
  establishment of formal diagnostic criteria for
  ADHD. 2. Not enough studies were included.

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Symptom trajectory studies

• Hart et al(1995) 1. Hyperactive-impulsive
  symptoms significantly declined with increasing
  age, whereas inattention symptoms did not. 2.
  Conduct problems predicted persistence of ADHD
  symptom. 3.Developmental changes in ADHD symptom
  did not vary as a function of informants 4.
  Psychosocial and pharmacological interventions
  did not reduce ADHD greatly.
• Biederman (1998)1.Children and adolescent ADHD
  did not differ in the mean number of ADHD
  symptoms. 2.Clinical phenotype is the same in
  adolescent and children.
• Biederman (on the same sample,2000) HIA
  decreased significantly as age increased.

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Developmental Trajectories of Brian volume
abnormalities in youth with ADHD

• Design MRI case control study
• M152 youth with ADHD and 139 controls of both
  genders
• Objectives assess volumetric changes overtime in
  medicated vs unmedicated youth with ADHD and
  controls
• Catellanous JAMA 2002 288-1740

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Developmental Trajectories of Brian volume
abnormalities in youth with ADHD

• Main Findings
• Smaller brain volumes in all regions
  independently of medication status
• Smaller total cerebral (-3.2)and cerebellar
  (-3.5) volumes
• Volumetric abnormalies(except caudate) persistent
  with age
• No gender differences
• Volumetric findings correlated with severity of
  AHDH

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Developmental Trajectories of Brian volume
abnormalities in youth with ADHD

• Conclusions
• Genetic and or early environmental influences on
  brain development in ADHD are fixed,
  nonprogressive and unrelated to stimulant
  treatment

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Maturation lag hypothesis

• Satterfield JH(1973,1984)ADHD children have more
  slow activity and less activity in the high
  frequency band---signs of immaturity reflecting a
  delayed brain maturation that could be normalized
  with age,or a deviation of brain maturation.
• Giedd JN(2001)ADHD cerebellum is significantly
  smaller than control.
• Lou (1984)SPECT findingmaturational lags of CNS
  resulting from delayed myelination.
• Castellanos (2002)gray matter shows complex
  developmental curves with a preadolescent
  increase but a post adolescent decrease.

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Limitations of developmental course studies

• Sample characteristics predominantly males in
  clinic referred sample
• Course of ADHD symptomatology differs as a
  function of comorbidity?
• The need to better understand whether reductions
  in ADHD(due either to sex and/or advancing age)
  are associated with specific changes in
  functional impairment that result from ADHD.
• Design issues
• Wide age range
• Time adjacent study that did not consider the
  functional form that characterizes this change
  over time

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More limitations

• Heterogeneity ADHD is not a homogenous disease
• Mendelson et al (1971)1/2 improved over time, ¼
  partial improved, ¼unchanged
• Loney (1981)developmental delay, developmental
  decay, continual display
• Lambert (1987,community cases)20 remitters,
  residuals 37, persisters (43)
• Hechtman of Montreal sample(1993)1/3 normal
  outcome, 1/2continual symptoms with function
  impairment, a minority experienced serious
  outcome.

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Implications

• Clinicians working with substance abuse
  populations, conduct disordered populations and
  head injury populations should be alert for ADHD.
• ADHD is a lifelong disorder

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Treatment options in comorbid ADHD

• Assess and treat all disorders
• Prioritized treatment
• Treatment of ADHD almost always involves the
  treatment of comorbidity
• Order of treatment
• Most debilitating symptoms first
• Consider interactions of symptoms and side
  effects of stimulants
• Simple case monotherapy
• Complex case- combined treatment

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Use of Ritain

• Absolute range per dose5-30 mg
• Weight-based dose range per day 0.3-2.0mg/kg

• There is no research to indicate more medicine
  with higher body weight
• Dose of medicine varied with individuals
  metabolism, severity of ADHD symptoms, presence
  of comorbid conditions, behavior characteristics
  and natural environment

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Side effect of Ritalin and its management

• Anorexia(generally lunch)-give with meals, snacks
• Insomnia- move dosing earlier, use of clonidine,
  TCA
• Mood disturbance- evaluate for mood disorder,
  assess timing of mood to r/o wear off effect
• Tic disorder- assess for underlying tics, stop
  and rechallenge
• Headache- lower dose, change prep, consider beta
  blocker
• Psychosis- rare, reassess dose and comorbid
• Delay growth spurt- drug holiday if inattentive
  form

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Non-stimulant pharmacotherapy

• TCA
• 60-70 effective, but generally less effective
  than stimulants
• Bupropion
• First line for ADHD substance abuse/cigarette
  use
• Maybe helpful in ADHD mood lability
• Clonidine
• Useful in ADHD tics
• Use at night for ADHD related sleep problem
• Concerns of sudden death case report of 4
  children(clonidine MPH)

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Treatment of ADHD with MDD

• Depression disorder
• If MDD is severe, then it is the focus of
  treatment
• If MDD is less severe or not primary, use
  stimulant trial first
• After stimulant trial, evaluate the depressive
  symptoms
• If depressive symptoms continue, use
  antidepressant or psychotherapeutic treatment
• SSRI effective for depression but not ADHD
• If depressive symptoms subsided, continue
  stimulants
• Bupropion and TCA have antidepressant activity in
  adult, but utility in pediatric use had nor been
  established(5 cases of sudden death in younger
  children)

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Treatment of ADHD with anxiety disorder

• Differentiate the relationship between ADHD and
  anxiety disorders
• Start with a stimulant trial
• If ADHD symptoms improve, but anxiety symptoms
  persisted, apply psychosocial intervention
• If the anxiety symptoms does not improve with the
  psychosocial intervention, consider adding SSRI
  to the stimulants.

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Treatment of ADHD with tics disorder

• High comorbidity of ADHD (50-70 TS patients)
• Onset of ADHD before tics
• Stimulants are highly effective in the treatment
  of ADHD in these patients and in the majority of
  patients tics do not increase
• Start the stimulant treatment after proper
  informed consent
• If tics worsen markedly, move on to an
  alternative stimulants
• If tics do not worsen, and ADHD symptoms respond,
  remain on the stimulants
• To treat the tics, consider combine medication,
  clonidine and guanfacine may be tried first

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Treatment of ADHD with conduct disorder and
aggression

• It stimulant did not reduce antisocial behavior
  despite the attenuation of the ADHD symptoms, use
  mood stabilizer(Li or divalproex sodium), or
  Clonidine in addition to stimulants(Frazier,
  1999)(4 deaths with the combination of Stimulants
  and Clonidine)
• Use of Clonidinestart with 0.05mg at bedtime,
  never more than 0.3 mg per day. Never use in
  patients with family history of sudden death,
  repeated fainting or arrhythmias.
• If aggression is severe, and is in immediate
  danger, use atypical neuroleptics, such as 0.5mg
  QD Risperidone, to the stimulants

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Prevention of Abuse potential of stimulants in
adolescents

• Locked the medicine, keep a record
• Do not use one students medicine on another
• Avoid sending medicine to school
• Use Concerta paste, taken once daily

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Oslon, 1959

• Those who surprised us seems to take a longer
  time to travel a given road, but that road has
  been kept open by parents and teachers who felt
  it worthwhile.