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Title: Attention%20Deficit%20Hyperactivity%20Disorder

Attention Deficit Hyperactivity Disorder
  • James H. Johnson, Ph.D., ABPP
  • University of Florida

ADHD Nature of the Problem
  • ADHD is a neurodevelopmental disorder of
    childhood that is characterized by
    developmentally inappropriate levels of
  • Hyperactivity,
  • Impulsivity,
  • Inattention.

ADHD How Common is it?
  • Prevalence is estimated at 3 to 9 per cent of the
    elementary school population.
  • ADHD occurs more often in males than females,
    with the sex ratio being about 4 to 1 to 9 to 1.
  • It is one of the most common disorders of
  • Accounts for a large number of referrals to
    pediatricians, family physicians and child mental
    health professionals.

ADHD Not a New Problem
  • Characteristics of this disorder have been
    recognized for at least a century.
  • The disorder has been referred to by a variety of
  • Minimal Brain Dysfunction (MBD)
  • Hyperkinetic Reaction of Childhood
  • Attention Deficit Disorder (ADD)
  • Attention Deficit Hyperactivity Disorder (ADHD)

ADHD Evolution of the Disorder
  • Still (1902) ADHD Case study
  • Encephalitis epidemic of 1917
  • Frontal lobe ablation studies with primates
  • Strauss work on Minimal Brain Dysfunction
    (1940's -1950's)
  • Beginnings of child psychopharmacology Using
    Amphetamines for treatment 1930-1940.
  • MBD becomes Hyperkinetic Disorder (the 1960s)

ADHD Evolution of the Disorder (cont.)
  • Hyperkinesis becomes ADD The decade of the 70s
  • Focus on Dietary Factors Feingold and the
  • Studies of psychophysiological responses of
    hyperactive children the 1970s
  • Development of objective diagnostic criteria DSM
  • Recognition of Attention Deficit Disorder The
    early 80s

ADHD Evolution of the Disorder (cont.)
  • The decade of the 80s DSM III DSM III-R
    stimulates ADHD research and the development of
    new assessment methods new treatment methods -
    increased focus on biological factors.
  • The 1990s - Present Neuroimaging, genetics and
    and a reevaluation of DSM.

ADHD Core Features
  • As noted earlier, ADHD is a disorder
    characterized by developmentally inappropriate
    levels of
  • Hyperactivity,
  • Impulsivity,
  • Inattention.

DSM IV Symptoms of Hyperactivity
  • Often fidgets with hands or feet, squirms in
  • Often leaves seat in classroom or in other
    situations in which remaining seated is expected
  • Often runs about or climbs excessively in
    situations in which it is inappropriate.
  • Often has difficulty playing or engaging in
    leisure activities quietly.

Hyperactive Symptoms
  • Is often "on the go" or often acts as if "driven
    by a motor.
  • Often talks excessively when inappropriate to the
  • A combined total of 6 or more of
    hyperactivity/impulsivity criteria are required
    for diagnosis.

What do we Know about Hyperactivity?
  • Children with ADHD are more active, restless, and
    fidgety than normal children during the day and
    during sleep.
  • There are different types of hyperactivity.
  • Gross Motor Activity
  • Restless/Squirmy
  • Occasionally see verbal hyperactivity
  • Hyperactivity often varies according to
  • Degree of hyperactivity may vary with age.

Symptoms of Impulsivity
  • Often blurts out answers before questions have
    been completed.
  • Often has difficulty awaiting turn.
  • Often interrupts or intrudes on others.
  • Six symptoms of hyperactivity and impulsivity
    are required for diagnosis.

Symptoms of Inattention
  • Often fails to give close attention to details or
    makes careless mistakes.
  • Often has difficulties sustaining attention in
    tasks or play activities.
  • Often does not seem to listen when spoken to
  • Often does not follow through on instructions and
    fails to finish homework, chores, or duties in
    the workplace

Symptoms of Inattention
  • Often has difficulty organizing tasks and
  • Often avoids, dislikes, or is reluctant to engage
    in tasks that require sustained mental effort.
  • Often loses things necessary for tasks or
  • Is often easily distracted by extraneous stimuli.
  • Is often forgetful in daily activities
  • (6 or more necessary for diagnosis)

What Do We Know About ADHD Attention Problems?
  • ADHD "attentional" problems may be most obvious
    on specific types of attentional tasks.
  • Children with ADHD seem to have their greatest
    difficulties with sustaining their attention in
    responding to tasks - in being vigilant.
  • Attention problems are usually seen most clearly
    in situations requiring the child to attend over
    time to dull, boring, and repetitive tasks.

Situational Variations in Symptoms
  • ADHD symptoms show significant variation across
  • Children with ADHD do not display symptoms in all
  • The absence of symptoms in some situations does
    not mean that the child does not have ADHD.

Situations That Increase ADHD Symptoms
  • When the demands of the situation are to be good,
    to be still, and to be quiet.
  • The greater the demands, the more problematic the
    behavior of the child will likely become.
  • An exception might be in situations where the
    child is being continuously rewarded for
    complying with demands.
  • In familiar situations where novelty and task
    stimulation are low.

Other Situations That Increase Symptoms
  • Situations where there are low rates of intrinsic
    or external reinforcement.
  • When the child is fatigued.
  • Studies, monitoring 24 hour activity levels have
    suggested that the hours of 1 5 seem to be peak
    times for increased activity in children with

Overview of Diagnostic Criteria
  • Symptom Criteria - Core Symptoms of Hyperactivity
    Impulsivity and/or Inattention (Six or More
    Symptoms of either category).
  • Duration Criterion - Symptoms have Persisted for
    at Least 6 Months.
  • Developmental Criterion - Symptoms are
    Inconsistent with Developmental Level.
  • Impairment Criterion - Clear Evidence of
    Clinically Significant Impairment in Social,
    Academic, or Occupational Functioning

Overview of Criteria (cont.)
  • Age Criterion - Some Symptoms that Cause
    Impairment Were Present Before Age 7.
  • Situation Criterion - Some Impairment from
    Symptoms is Present in Two or More Settings.
  • NOTE. The failure to attend to full range of
    symptoms is not uncommon
  • Presence of hyperactivity, impulsivity, and
    inattention is not necessarily to be equated with

Types of ADHD
  • Combined Type
  • Symptoms of hyperactivity, impulsivity and
  • Hyperactive/Impulsive
  • Symptoms of hyperactivity and impulsivity.
  • Predominately Inattentive
  • Symptoms of inattention.

ADHD Mimicry
  • Sensory Impairments
  • Medication side effects
  • Phenobarbital
  • Dilantin
  • Some Asthma Medications
  • Seizure Disorder
  • RTH (Resistance to Thyroid Hormone)
  • PTSD
  • Bipolar Disorder
  • Anxiety Disorders
  • Depressive Disorders

Comorbid Conditions
  • What are comorbid conditions?
  • Controversy over use of the term.
  • Why is it essential to consider the possibility
    of comorbid conditions in assessing children with
  • Importance of distinguishing between comorbid
    conditions and mimicry.
  • What is the frequency of comorbidities in
    children with ADHD?

Comorbid Conditions
  • Learning Disabilities - 19 to 26
  • Oppositional Defiant Disorder - 40 Conduct
    Disorder - 25 children 45-50 Adolescents.
  • Anxiety Disorders - 30
  • Depressive Disorder - 10 - 30
  • Bipolar Disorder up to 20.
  • Tics and Tourettes Disorder 7 of children
    with ADHD have a tic disorder.
  • 40 to 50 of those with Tourettes disorder have

Developmental Issues
  • There are factors in infancy, such as difficult
    temperament, that appear to be early precursors
    of ADHD.
  • Initial development of ADHD is most often during
    the preschool years.
  • While there is often a decline in the level of
    hyperactivity and some improvement in attention
    and impulse control in adolescence, perhaps 80
    continue to be impaired by their symptoms and
    meet current diagnostic criteria.
  • A significant number of children with ADHD
    (probably over 50) continue to display problems
    into the adult years.

Prognosis of ADHD
  • Outcome of ADHD in adolescents is highlighted by
    the results of a study by Barkley, Fischer, et
    al, (1990).
  • This study followed a large sample of ADHD (158)
    and normal children (81) prospectively for 8
    years after diagnosis.
  • 123 hyperactive children and 66 normals were
    located, interviewed and complete questionnaires.
  • In the hyperactive group 12 (9.7) were female
    and 111 were male. In the normal group 4 of the
    subjects were female and 62 were male.

Prognosis In Adolescence
  • The vast majority of the hyperactive subjects
    (71.5) met DSM III-R criteria for ADHD at follow
  • More than 59 met criteria for Oppositional
    Defiant Disorder as compared to 11 of the
  •  Approximately 43 of the hyperactive group
    could be diagnosed as CD as compared to 1.6 of
    the control group.

Prognosis Continued
  • Hyperactive subjects were more likely to have had
    an auto accident, to have had more automobile
    accidents, to have had more bodily injuries in
    accidents, and to be at fault for accidents more
    often than did controls.
  • Adolescents in the hyperactive group were also
    more likely to have received traffic citations,
    especially for speeding

Prognosis Continued
  • Cigarette and alcohol use were the only
    categories of substance use that differentiated
    hyperactives and normals.
  • When the the hyperactive sample was separated
    into groups (purely ADHD and ADHD CD) purely
    ADHD subjects showed no greater use of
    cigarettes, alcohol, or marijuana than did normal
  • Mixed hyperactive/Conduct disordered children
    displayed two to five times the rate of substance
    use as did pure hyperactives or normals.

Prognosis Continued
  • Three times as many hyperactives had failed a
    grade (29.3 versus 10), had been suspended
    (46.3 versus 15.2) or had been expelled (10.6
    versus 1.5).
  • Results indicated that hyperactivity alone
    increases the risk of suspension (30.6 vs
    15.2), and dropping out
  • (4.8 vs 0 ) as compared to controls
  • However, the added diagnosis of CD greatly
    increases the risk (67 suspended, 13 dropped
  • The presence of CD accounted almost entirely for
    the gt risk of expulsion within the hyperactive

Prognosis In Adulthood
  • As many as 67 of children diagnosed with ADHD
    will display symptoms in adulthood serious enough
    to interfere with academic, vocational or social
  • There are indications that the type of ADHD that
    persists into adulthood is more highly genetic
    than the type that remits in childhood.
  • ADHD in adults is sometimes considered a hidden
    disorder as symptoms are often obscured by other
  • Prevalence is thought to be 2 4 with sex ratio
    of 2 1 or lower).

Risk Factors
  • Maternal cigarette use
  • Maternal alcohol use
  • Unusually long or short labor
  • Forceps delivery
  • Toxemia
  • Meconium staining
  • Birth during the month of September.
  • Minor physical anomalies

Etiology - Genetics
  • Between 10 and 35 per-cent of the immediate
    family members of children with ADHD also display
    this disorder.
  •  Risk for siblings of children with disorder is
    approximately 32
  • If a parent has ADHD the risk to offspring is on
    the order of 50
  • Twin studies suggest concordance rates for
    monozygotic twins is around 80 with concordance
    rates of approximately 30 for dizygotic twins.
  • Overall, twin studies suggest an average
    heritability of .80

Etiology Molecular Genetics
  • Molecular genetics has begun to identify specific
    genes related to ADHD.
  • A dopamine type 2 gene has been found to be
    related to ADHD as well as Tourettes and
  • More recently a "dopamine transporter gene" and a
    dopamine repeater genehave been identified.
  • This gene, found to be related to ADHD in
    multiple studies, seems to be related to
    post-synaptic sensitivity in the frontal and
    prefrontal cortical regions and to be associated
    with executive functions.

Genetic Contributions (cont.)
  • With developments in molecular genetics occurring
    at an increasingly rapid rate (due to the Human
    Genome Project), in the near future, we may have
    genetic tests that can provide early screening
    for ADHD and possibly associated comorbidities.
  • Genetic factors are clearly strongly implicated
    in the development of this disorder.
  • Hereditary is one of the most well supported
    etiological factors in the development of ADHD

Etiology Neurological Insult
  • Multiple factors that can result in brain damage
    are associated with ADHD.
  • For example, anoxia, is associated with increased
    frequencies of hyperactivity and attentional
  • ADHD occurs more often in children with seizure
    disorders, who are presumed to have neurological
  • As was noted earlier, diseases such as
    encephalitis can also result in symptoms of ADHD
    as can various types of infections.

Etiology Brain Damage
  • These findings suggest that neurological insult
    can result in an increased probability of
    developing ADHD.
  • However, most children with ADHD do not have a
    significant history of brain injury.
  • Indeed, such injuries are unlikely to account for
    ADHD in most children.
  • In fact probably 95 of hyperactive children show
    no evidence of documentable neurological
  • This does not mean, however, that neurological
    factors are not involved.

Neuropsychological Test Findings
  • Results from research involving
    neuropsychological testing has often suggested
    that children with ADHD have problems
  • in inhibiting behavioral responses,
  • with working memory,
  • with planning and organization,
  • with verbal fluency,
  • with perserveration,
  • In motor sequencing,
  • with other frontal lobe functions.

Research with Neuropsychological Testing (Cont.)
  • Not only do children with ADHD show executive
    functioning deficits but siblings of ADHD
    children who do not have ADHD, have milder yet
    significant impairments of the same type.
  • This suggests a possible genetic risk for
    executive function deficits in families.

Cerebral Blood Flow
  • Studies of cerebral blood flow in ADHD and normal
    children have consistently shown decreased blood
    flow to the prefrontal regions and pathways
    connecting these regions to the limbic system via
    the striatum and specifically its anterior region
    (the Caudate Nucleus)
  • Studies using PET scans to assess cerebral
    glucose metabolism in the frontal regions have
    found diminished metabolism in, adults and
    adolescent females with ADHD.

Cerebral Blood Flow Continued
  • Significant correlation's between diminished
    metabolic activity in the left anterior frontal
    region and severity of symptoms in adolescents
    with ADHD have also been demonstrated
  • This demonstration of a relationship between
    decreased metabolic activity of certain brain
    regions and severity of ADHD symptoms is crucial
    to documenting the importance of the link between
    brain activation and behaviors associated with

Frontal Lobes
Basal Ganglia
Striatal Network
MRI Studies
  • Early studies found differences in the Corpus
    Callosum, with this structure being smaller in
    children with ADHD. Not always replicated.
  • Other MRI studies have found children with ADHD
    to have a smaller left caudate nucleus than did
    normal children. These findings are interesting
    in light of the results of earlier blood flow
    studies suggesting lower levels of activation in
    this specific area in children with ADHD.

MRI Continued
  • Several more recent MRI studies, with larger
    samples, have replicated these early results by
    finding that ADHD children had significantly
    smaller anterior right frontal regions, a smaller
    caudate nucleus, and smaller golbus pallidus
    regions that normals.
  • Research has also found decreased cerebellar
    volume in ADHD children.
  • Work in this area suggests that abnormalities in
    the development of the frontal-striatal regions
    may well underlie the development of ADHD.

Neurotransmitter Deficiencies
  • The possibility of a neurotransmitter dysfunction
    in children with ADHD has been suggested for many
  • This notion seemed to originate from observations
    of the response of children with ADHD to
    different type of stimulant drugs.
  • The fact that stimulant drugs have an impact on
    ADHD and that they increase dopamine has
    contributed to the neurotransmitter dysfunction

Neurotransmitter Deficiencies
  • There is more direct evidence of neurotransmitter
    deficiencies from studies of cerebral spinal
    fluid in ADHD and normal children which suggests
    decreased dopamine levels in ADHD children
  • There is also some evidence of a deficiency in
    the availability of norepinephrine in children
    with ADHD.
  • This is of interest given that a very new
    non-stimulant ADHD medication, Straterra, is
    thought to act on norepinephrine levels.

Etiology Psychosocial Factors
  • There is little evidence for the role of
    psychosocial factors in the development of ADHD,
    although factors such as parent-child conflict
    may exacerbate problems in a child with ADHD.
  • Psychosocial factors may also contribute to the
    development of certain comorbid disorders that
    may complicate the clinical picture.

Etiology Overview
  • In reviewing the literature on the etiology of
    ADHD, Barkley suggests
  • It should be evident from the researchthat
    neurological and genetic factors make a
    substantial contribution to symptoms of ADHD and
    the occurrence of this disorder.
  • A variety of genetic and neurological etiologies
    (e.g., pregnancy and birth complications,
    acquired brain damage, toxins, infections, and
    genetic effects) can give rise to the disorder
    through some disturbance in a final common
    pathway in the nervous system.

Overview Continued
  • That final common pathway appears to be the
    integrity of the prefrontal cortical-striatal
  • It now appears that hereditary factors play the
    largest role in the occurrence of ADHD symptoms
    in children.
  • It may be that what is transmitted genetically is
    a tendency toward a smaller and less active
    prefrontal-striatal network.

Overview Continued
  • The condition can also be caused or exacerbated
    by pregnancy complications, exposure to toxins,
    or neurological disease
  • Social factors alone cannot be supported as
    causal in this disorder, but such factors may
    exacerbate the condition, contribute to its
    persistence, and more likely, contribute to the
    forms of comorbid disorders associated with ADHD.
  • Cases of ADHD can arise without genetic
    predisposition if the child is exposed to a
    significant disruption or neurological injury to
    this final common neurological pathway, but this
    would seem to account for only a small minority
    of ADHD children.

Treatment of ADHD
  • Stimulant Medications
  • Other Medications
  • Psychosocial Treatments
  • Educational Accommodations

Commonly Used Stimulant Medications
  • Ritalin
  • Dexadrine
  • Adderall
  • Concerta
  • Between 70 and 80 of children with ADHD respond
    positively to stimulant drugs.
  • Stimulant drugs represent an empirically
    supported treatment for core symptoms of ADHD.

Side Effects of Stimulants
  • Common side effects can include loss of
    appetite, weight loss, sleeping problems,
  • restlessness, stomachache, headache, rapid heart
    rate, elevated blood pressure, sudden
    deterioration of behavior
  • symptoms of depression with sadness, crying, and
    withdrawn behavior.
  • intensification of tics (muscle twitches of the
    face and other parts of the body), possible
    Tourettes and growth suppression.

Side Effects (Cont.)
  • While side effects are always a possibility they
    are often
  • Transient in nature
  • The result of inappropriate medication levels
  • If one medication results in side effects,
    another might be used without side effects.
  • Sometimes other medications are used to minimize
    side effects.
  • Good clinical judgment by the clinician may help
    to minimize side effects.

Some Examples of NonStimulant Drugs in ADHD
  • Non Stimulant ADHD Medication
  • Straterra - a norepinephrine reuptake inhibitor-
    selectively blocks the reuptake of
    norepinephrine, which increases its availability
  • Other Non Stimulant Drugs
  • Anti-depressants (e.g., Tofranil, Wellbutrin)
  • Anti-hypertensives (Clonidine)

Psychosocial Treatments
  • Parent Training
  • Social Skills Training
  • Cognitive Behavioral Treatments.
  • Psychotherapy for comorbid conditions

Educational Interventions
  • Special Education Services for existing learning
  • Classroom accommodations.
  • Classroom behavior modification programs.

ADHD Treatment Concluding Comments
  • In treating ADHD it is essential to treat the
    full range of difficulties that impact on child
    and family functioning.
  • Treatment of ADDH will often need to be
    multimodal in nature.
  • Findings from the Multimodal Treatment Study
    suggest that
  • Stimulant medication is effective in reducing
    core symptoms
  • Psychosocial treatments are of value in
    addressing associated comorbidities.

Thats All Folks!
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