Attention Deficit Hyperactivity Disorder (ADHD)

The ADHD Story

ADHD a Neurobiological Condition is related to SLD

Attention Deficit Hyperactivity Disorder (ADHD) - with Inattention and/or Impulsivity Specific Learning Disability (SLD) - with Auditory, Visual or Kinesthetic Processing Problems including Dyslexia/Reading Disorder

Other Neurobiological Conditions Related to ADHD:

Central Auditory Processing Disorder (CAPD) Sensory Integration Disorder Motor Planning Disorder Self-Regulatory Disorder Autistic Spectrum Disorder - PDD, MSD, Globally Delayed, Autistic Neurological Conditions: Epilepsy, Tourette Syndrome
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ADHD Characteristics

Inattention Impulsivity Overactivity

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Attention Deficit Hyperactivity Disorder

Inattention - Traditionally known as ADD Impulsivity - Traditionally known as Hyperactivity

Inattention-Distractibility
Doesn t seem to listen Fails to finish assigned tasks Often loses things Can t concentrate Easily distracted Daydreams Requires frequent redirection Can be very quiet & missed
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Impulsivity-Behavioral Disinhibition
Rushing into things Careless errors Risk taking Taking dares Accidents/injuries prone Impatience Interruptions
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Hyperactivity - Overarousal
Restlessness Can t sit still Talks excessively Fidgeting Always on the go Easy arousal Lots of body movement
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Different Names for ADHD Through the years:

1902 Defects in moral character 1934 Organically driven 1940 Minimal Brain Syndrome 1957 Hyperkinetic Impulse Disorder 1960 Minimal Brain Dysfunction (MBD) 1968 Hyperkinetic Reaction of Childhood (DSM II) 1980 Attention Deficit Disorder - ADD (DSM III) with-hyperactivity without-hyperactivity residual type

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Names for ADHD

1987 Attention-Deficit Hyperactivity Disorder or Undifferentiated Attention Deficit Disorder (DSM III-R) 1994 Attention-Deficit/Hyperactivity Disorder (DSM IV) 314.01: ADHD, Combined Type 314.00: ADHD, Predominantly Inattentive type 314.01: ADHD, Predominantly HyperactiveImpulsive Type
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ADHD Epidemiology
Prevalence
Survey average: 8-10% in children of school age Parent reported prevalence age 4-17
Boys 11% Girls 4.4%

Male: Female ratio

2:1 - 4:1

ADHD Pathogenesis
Multiple theories
Imbalance of catecholamine metabolism in cerebral cortex Impaired executive functions Impaired response inhibition

DSM IV Criteria ADHD (Inattention) careless mistakes in Often fails to give close attention to detail or makes
schoolwork, work or other activities. Often has difficulty sustaining attention in tasks of play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish homework, chores or other duties Often has difficulty organizing tasks and activities Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort Often loses things required to complete tasks Is often easily distracted Is often forgetful in daily activities
Six (or more) of the following symptoms have persisted for at least six months to a degree that is maladaptive or not consistent with development level.

DSM IV Criteria ADHD (Hyperactivity)

Often fidgets with hands or feet or squirms in seat Often leaves seat in situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate Often has difficulty in playing quietly Is often on the go or acts as if driven by a motor Often talks excessively Often blurts out answers before questions are completed Often has difficulty waiting turn Often interrupts of intrudes on others

Six (or more) of the following symptoms have persisted for at least six months to a degree that is maladaptive or not consistent with development level.

Diagnosis of ADHD
Additional Criteria:
Some inattentive or hyperactive/impulsive symptoms were present before the age of seven. Some impairment from the symptoms is present in two or more settings (e.g. at school and at home) Clear evidence of clinically significant impairment in social, academic or occupational functioning

DSM IV Criteria - ADHD

Three types
Inattention predominant (ADHD-IA) (30-40%) Hyperactivity predominant (ADHD-H/I) (10%) Combined type (ADHD-C) (50-60%)

Diagnosis of ADHD
Screening questions
How is your child doing in school this year? Is your child happy to go to school? Have you heard from the teacher(s) regarding any concerns about behavior or performance in school? How does your child do with chores around the house? How does your child do with homework?

Learning disabilities

Tourette s Syndrome

Conduct Disorder

Attention Deficit Hyperactivity Disorder

Depression

Anxiety Oppositional defiant disorder

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Diagnosis of ADHD
Objective approach
Data needs to be collected from more than one source
Parents Teachers Others

Diagnosis of ADHD
What kind of data?
Standardized forms
Conners Rating Scale (CATRS) ACTeRS Form Vanderbilt ADHD Diagnostic Rating Scale

Diagnosis ADHD
Need to develop a differential diagnosis

What Research is Telling Us about ADHD

Genetically transmitted in 70-95% of cases Results from chemical imbalance or deficiency in certain neurotransmitters-chemicals which help brain regulate behavior Rate at which brain uses glucose, its main energy source, is lower in subjects with ADHD than those without (Zametkin et al, 1990) Depressed release of Dopamine might have role in ADHD (Volkow et al, 2003)
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Research also tells us about ADHD that:

Central pathological deficits of ADHD are linked to several specific brain regions Frontal Lobe Its connections to Basal Ganglia Their relationships to central aspect of Cerebellum Less electrical activity in brain & show less reactivity to stimulation in one or more of above brain regions Brains are 3-4% smaller-in more severe-frontal lobes, temporal gray matter, caudate nucleus & cerebellum were smaller
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MRI in ADHD

MRI in ADHD
They show subtle structural differences in these regions of the ADHD brain: prefrontal cortex - especially the smaller right anterior frontal cortex, and also less white matter in the right frontal lobes which cause problems with sustained or focused attention, caudate nucleus - asymmetries which cause problems with self-control, globus pallidus right hemisphere - the studies show that the right hemisphere of the ADD ADHD brain is, on average, 5% smaller than the control groups

PET Scan of Metabolism of Glucose Adult Brain with ADHD

Positron Emission Tomography (PET) Pictures of Adult with ADHD Normal Adult

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ADHD & LD lead to Diminished Executive Functions

Deficient self-regulation of behavior, mood, response Impaired ability to organize/plan behavior over time Inability to direct behavior toward future Diminished social effectiveness & adaptability

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What is the Impact of these Disorders?

Neurologically based behavioral issues can keep child from developing normally Lack of full coordination of gross & fine motor skills Lack of complete age appropriate speech, language & communications Impaired self-esteem
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What is the Extent of ADHD?

About 3% of school-aged population have full ADHD symptoms & another 5-10% have partial ADHD Another 15-20% of school-aged population show transient behaviors suggestive of ADHD Boys are 3 times more likely than girls to have ADHD Symptoms decrease with age but 50-65% of children still manifest symptoms into Adulthood (Korn & Weiss, 2003)

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What is the Impact of ADHD on people? (Barkley, 2002)

32-40% of students with ADHD drop out of school Only 5-10% will complete college 50-70% have few or no friends 70-80% will under-perform at work 40-50% will engage in antisocial activities More likely to experience teen pregnancy & sexually transmitted diseases Have more accidents & speed excessively Experience depression & personality disorders
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What is the Impact of these Disorders?

35% of students with learning disabilities drop out of school 30% of adolescents with learning disabilities will be arrested 3 to 5 years out of High School (Wagner et al,
1993)

Previously undetected learning disabilities have been found in 50% of juvenile delinquents - Once treated their recidivism drops to just 2% (Lerner, 1997)
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Diagnosis of ADHD
Oppositional Defiant Disorder Conduct Disorder Depression Anxiety Learning disability Special senses disability Substance Abuse Pervasive Developmental Delay NOS

Oppositional Defiant Disorder

A pattern of negativistic, hostile and defiant behavior lasting at least six months, during which four or more of the following are present:
Often loses temper Often argues with adults Often actively defies or refuses to follow adults rules Often deliberately annoys people Often blames others for his/her mistakes Often is touchy / easily annoyed by others Often is resentful Often is spiteful / vindictive

The disturbance in behavior causes significant impairment in social, academic or occupational functioning. The symptoms are not due to a mood disorder or conduct d/o.

Conduct Disorder
Repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate norms or rules of society are violated.
Aggression to people or animals Destruction of property Deceitfulness or theft Serious violation of rules

Depression
Depressed mood Change in sleep (S) Loss of interest / pleasure in activities (I) Thoughts of worthlessness or guilt (G) Loss of energy (E) Trouble concentrating (C) Change in appetite or weight (A) Change in psychomotor activity (P) Thoughts of suicide or death (S)

5 of the 9 symptoms present frequently for at least two weeks. One of the 5 symptoms must be depressed mood or loss of interest in usual activities. Symptoms can not be due to substance use of another psychiatric diagnosis.

Learning Disability
Schoolwork performance issues
Reading Writing Mathematics

Special Senses Disability

Visual disturbance Hearing loss

Substance Abuse
High index of suspicion in teens

Pervasive Developmental Delay NOS

Autistic spectrum, but not meeting autism criteria

When should I refer a child I suspect has ADHD?

Age younger than six Co-existent psychiatric conditions Co-existent neurologic conditions

Let s go to Vanderbilt

ADHD Management Plan

Clear communication with parents and teachers
Phone calls Email Progress notes Daily School-Home Report Card

ADHD Management Plan

Parenting skills
Homework rules Sleep rules T.V. / Videogame rules

ADHD Management Plan

Stimulant Medications
Dextroamphetamine / Levoamphetamine
Adderall Adderall XR

Dextramphetamine
Dexedrine Dexedrine Spansule Dextrostat

Methyphenidate
Ritalin Ritalin LA Ritalin SR Concerta Methylin Metadate ER Metadate CD Focalin Daytrana

ADHD Management Plan

Stimulant Medications
Adverse effects
Anorexia Weight loss Sleep disturbance Tics Tachycardia Hypertension

ADHD Management
Stimulant Medication
Use the least amount needed Use extended release preparations when possible Give drug holidays if appropriate Reassess regularly as to response

ADHD Management
Stimulant Medications are Schedule 2 drugs
30 day supply with written prescription Rule change 2007 allows up to 90 day supply
Three 30 day scripts Each dated sequentially for fill date

Atomoxetine is not a restricted medication

ADHD Management Plan

Non stimulant medication
Atomoxetine (Strattera)
Norepinephrine reuptake inhibitor Starting dose 0.5 mg/kg Maximum dose 1.4 mg/kg or 100 mg /day ADHD scores improve with atomoxetine vs placebo ADHD scores are equal to / slightly worse than stimulant medications

ADHD Management
Non-stimulant Medication
Atomoxetine side effects
Anorexia Weight loss Abdominal pain Nausea / Vomiting Sleep disturbance Suicidal ideation (0.4% vs 0% placebo) Liver injury (VERY RARE -- 2 cases!)

When else should I refer a child I suspect has ADHD?

Failure to respond to a reasonable trial of stimulant / non-stimulant medications and behavior interventions

Conclusions: ADHD
Performing an ADHD evaluation is within the spectrum of practice of a family doctor Observer data is needed from at least two settings in the child s life Co-morbid / alternate diagnoses should be ruled out A comprehensive management plan offers the patient the best chance for success in school

ADHD Resources
Caring for Children with ADHD: A Resource Toolkit for Clinicians, AAP, 2008.
http://www.nichq.org/NICHQ/Topics/ChronicConditions /ADHD/Tools/ Individual forms are available here for download http://www.nichq.org/resources/toolkit A compressed folder of all ADHD forms is available for download.

Additional References
Changes and Challenges: Managing ADHD in a Fast-Paced World, Michael J Manos, et al, Manag Care Pharm. 2007;13(9)(suppl S-b):S2S13 Obtaining Systematic Teacher Reports of Disruptive Behavior Utilizing DM-IV, Mark L. Woraich, et al, Journal of Abnormal Child Psychology, Vol 26(2), 1998: 141-152.

Adult ADHD
Childhood ADHD commonly persists:
22-85% of adolescents 4-50% of adults

Adult ADHD
Symptom complex can differ from childhood
Inattention and impulsivity > hyperactivity

Adult ADHD
Wender (Utah) Criteria
Hyperactivity and inattention plus (2) of below
Labile emotions Hot temper Inability to complete tasks Inability to tolerate stresss Impulsivity

Adult ADHD
Treatment
Stimulants
Response rate decreased versus childhood ADHD

Atomoxetine
Lower cadiovascular risk profile Minimal abuse potential

Management of ADHD
Stimulant Misuse (22%) / Diversion (11%)
Continuously escalating dosage Repeated lost prescriptions / dispensing errors Demand for immediate release preparation Infrequent user Psychosis Palpatations