Attention-Deficit Hyperactivity Disorder

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Attention-Deficit Hyperactivity Disorder

• Melissa Stern, M.S.
• mkstern_at_phhp.ufl.edu

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A Day in the life of.
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Attention-Deficit/Hyperactivity Disorder

• ADHD is a neurodevelopmental disorder of
  childhood that is characterized by
  developmentally inappropriate levels of
• Hyperactivity
• Impulsivity
• Inattention

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ADHD Prevalence

• 3-9 of the elementary school population
• more often in males than females, with the sex
  ratio being about 31 to 91
• most common disorders of childhood accounting for
  a large number of referrals to pediatricians,
  family physicians and child mental health
  professionals

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ADHD 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

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History of ADHD

• Characteristics of this disorder have been
  recognized for at least a century
• The disorder has been referred to by a variety of
  labels
• Minimal Brain Dysfunction (MBD)
• Hyperkinetic Reaction of Childhood
• Attention Deficit Disorder (ADD)
• Attention Deficit Hyperactivity Disorder (ADHD)

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History of ADHD

• Characteristics of this disorder have been
  recognized for at least a century
• The disorder has been referred to by a variety of
  labels
• Minimal Brain Dysfunction (MBD)
• Hyperkinetic Reaction of Childhood
• Attention Deficit Disorder (ADD)
• Attention Deficit Hyperactivity Disorder (ADHD)

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History of ADHD

• 1980s
• DSM III DSM III-R stimulates ADHD research
• development of new assessment methods
• new treatment methods
• increased focus on biological factors.
• 1990s
• Neuroimaging
• genetics
• reevaluation of DSM

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DSM-IVHyperactivity

• Often fidgets with hands or feet, squirms in seat
• 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

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DSM-IVHyperactivity

• Is often "on the go" or often acts as if "driven
  by a motor
• Often talks excessively when inappropriate to the
  situation
• 6 or more of hyperactive and/or impulsive
  symptoms required for diagnosis

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More on 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
• Verbal hyperactivity
• Hyperactivity often varies according to situation
• Degree of hyperactivity may vary with age

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DSM-IVImpulsivity

• 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

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DSM-IVInattention

• 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
  directly
• Often does not follow through on instructions and
  fails to finish homework, chores, or duties in
  the workplace

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DSM-IVInattention

• 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 necessary for tasks or
  activities
• Is often easily distracted by extraneous stimuli.
• Is often forgetful in daily activities
• 6 or more symptoms needed for diagnosis

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More on Inattention

• Attentional" problems may be most obvious on
  specific types of attentional tasks
• sustained attention responding to tasks, being
  vigilant
• situations requiring the child to attend over
  time to dull, boring, and repetitive tasks

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Diagnostic Criteria Overview

• 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

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Diagnostic Criteria

• 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

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Types of ADHD

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

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Impairment in ADHD

• Social Impairment What does it look like?
• Academic Impairment Long term outcomes for
  children with ADHD not so good
• Family Impairment
• Occupational Impairment
• Driving Impairment

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ADHD Across the Lifespan

• ADHD is a chronic disorder
• 60-80 of children continue to meet diagnostic
  criteria in Adolescence
• 50-70 of children will continue to meet
  diagnostic criteria in Adulthood
• ADHD in childhood is different from adolescence
  and different from adulthood

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Presentation of ADHD in Adolescence

• Gross motor activity tends to disappear
• Predominance of Inattention, Restlessness (rather
  than hyperactivity) and impulsivity
• What is a developmentally appropriate level of
  impulsivity in adolescence?

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ADHD in Adults

• More similar to adolescent presentation
• Mainly problems with inattention and impulsivity
• How much inattention and impulsivity affect an
  adult male? A father? A store clerk?
• Impairment is key

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Occupational Impairment

• Similar problems to those seen in the academic
  environment
• Often unprepared, untimely, easily distracted
• Under Achievers

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Social Impairment

• Still there in adolescence and adulthood!
• If you dont attend when people talk, they often
  think you arent interested

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Sensation Seeking/Substance Use

• Adolescents and adults with ADHD are more likely
  than those with out to engage in risky behavior
  including
• Marijuana use
• Alcohol Use
• Drunk Driving
• This is true even when accounting for the
  presence of oppositional defiant disorder and/or
  conduct disorder

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Driving impairment

• Leading cause of death in 15-24 year olds are
  motor vehicle accidents
• Adolescents and adults with ADHD are more likely
  to have an accident, to have more accidents, to
  speed, to receive traffic citations, to receive
  more traffic citations, to have their licenses
  suspended/revoked, to drive without a license, to
  drive under the influence

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Driving Impairment

• One of the most common causes of MVAs is plain
  old inattention
• Adolescents in particularl are more likely to
  speed, to not use a seatbelt, and to drink and
  drive
• Hmm.what does this mean for people with ADHD

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Virtual Reality

• Researchers are using virtual reality to simulate
  driving situations and assess performance
• Here at UF we have a high tech simulator
• http//driving.phhp.ufl.edu/

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Shameless Plug

• Driving Impairment in ADHD is my area of research
• I am going to need an RA or two to help with my
  dissertation starting in the Spring or next fall
• If you are a sophomore or junior and are
  interested in getting into research, EMAIL ME! ?
  mkstern_at_phhp.ufl.edu

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But What About Cognitive Impairment

• Its a NEUROdevelopmental disorder, right?
• So why hasnt this lady mentioned cognitive
  problems?

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ADHD Neuropsychological Deficits

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

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Neurological Findings

• Siblings of children with ADHD who do not have
  ADHD, have milder yet significant impairments in
  executive functions
• This suggests a possible genetic risk for
  executive function deficits in families

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Other Neurological Findings

• Differences in cerebral blood flow
• Differences in cerebral metabolism
• Differences in the corpus collosum

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Neurotransmitter Deficits

• Neurotransmitter dysfunction in children with
  ADHD has been suggested for many years
• Originated 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
  hypothesis

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Comorbidity ADHD

• Why is it essential to consider the possibility
  of comorbid conditions in assessing children with
  ADHD?
• Importance of distinguishing between comorbid
  conditions and mimicry
• What is the frequency of comorbidities in
  children with ADHD?

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Comorbidities

• 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
  ADHD

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Onto Assessment and Diagnosis!
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American Academy of Pediatrics Guidelines

• Only governing organization with guidelines for
  ADHD assessment
• Designed for pediatricians
• Move toward guidelines in APA

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The Interview

• Structured or semi-structured
• Gold Standard is The Barkley
• Parent and Self-Report versions
• Mostly used in research
• Goal is to assess for the three main symptom
  areas and evidence of impairment which meets DSM
  criteria

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Behavioral Observations

• This isnt technically recommended by AAP
• However, if a child is literally climbing the
  walls, it might be good to note that
• Always remember that children may be inclined to
  be on their best behavior in new situations
• Coding systems available for looking at
  hyperactive and inattentive behaviors

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Parent-Report Rating Scales

• Shorter measures which ask parents about
  frequency, severity, etc. of various behaviors
• Recommended by AAP but not required
• Conners Parent Rating scale the Gold Standard
  form
• Assesses various aspects of inattention,
  hyperactivity, impulsivity

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CPRS

• Items are rated on a four-point scale from Not
  at all true to Very much true
• 87 questions
• Each question is part of one or more subscales
• The parents rating on a given question
  corresponds to a number 0-3
• You sum the numbers for that scale
• You plot subscale sums on the profile chart
• Scores in the red area are indicative of greater
  problems

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Parent-Report Broadband Measure

• Broadband measures assess a wide array of social,
  emotional, and behavioral problems
• They are not recommended for AAP for ADHD
  diagnosis
• However, they are USEFUL for identifying comorbid
  areas of concern (aggression/conduct problems,
  depression)

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Teacher Reports

• These are essential in assessing for ADHD
• Need to identify impairment in MULTIPLE SETTINGS
• Most children with ADHD will have academic
  impairment
• Teachers may have the best knowledge of
  developmentally appropriate levels because they
  work with so many children

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Teacher Reports

• There is a teacher version of the CPRS, called
  the Conners Teacher Rating Scale (CTRS)
• Modified for the classroom setting but scored the
  same way
• There are also teacher equivalents of broadband
  measures

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Problems with Parent and Teacher Report

• Always the issue of informant bias (wanting to
  look like a good parent, like a teacher who can
  handle kids)
• Sometimes difficult to get in contact with
  teachers and they often dont return forms
• CPRS and BASC may be biased towards
  non-European-American Children

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Detour Multicultural Issues in ADHD

• ADHD is not limited to the U.S.
• It is seen cross-culturally
• However, there is concern it is over-diagnosed in
  Low SES and minority children
• Compared to parents of Caucasian children,
  parents of African-American and Hispanic children
  have reported significantly more often feeling as
  though their children are over-diagnosed and
  over-medicated

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Detour Multicultural Issues In ADHD

• Parents of African-American children less likely
  to associate school problems with ADHD and are
  less likely to request behavioral interventions
  compared to parents of Caucasian children
• Parents of African-American children more likely
  to report not knowing the etiology of ADHD and
  where to go to receive treatment for the disorder
  compared to parents of Caucasian children

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Detour Multicultural Issues In ADHD

• In studies looking at cross-cultural validity of
  several ADHD assessments, found that parents of
  African-American children had significantly
  higher scores compared to parents of Caucasian
  children. Similar findings for teacher ratings
• Unclear as to whether this is due to informant
  biases, cultural biases of the measure, or actual
  ethnic differences
• This continues to be an area needing research

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Detour Multicultural Issues In ADHD

• What we do know
• African-American Children respond equally well to
  medication treatment compared to Caucasian
  children
• Generally no differences in doses of medication
• Multimodal treatment superiority effect for
  minority children (we will get back to this in a
  moment)

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Cognitive Measures

• Not recommended for use in diagnosis
• Most evaluators use them in combination with many
  other measures.
• These are lab measures that directly assess
  impulsivity, inattention, and executive function

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The CPT

• Measures attention and impulsivity
• Various ways to administer it, but here we use
  the everything but X paradigm
• Lets see what this looks like

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TREATMENT ADHD treatment
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Treatment of ADHD

• Stimulant Medications
• Other Medications
• Psychosocial Treatments
• Educational Accommodations

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Stimulant Medications

• Ritalin
• Dexadrine
• Adderall
• Concerta
• 70-80 of children with ADHD respond well to
  stimulant drugs
• Stimulant drugs represent an empirically
  supported treatment for core symptoms of ADHD
• Stimulants are a trial and error method

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Stimulant Side Effects

• loss of appetite, weight loss, sleeping problems,
  irritability
• 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
• Long term effects?

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Stimulant Side Effects

• Side effects are often
• transient in nature
• result of inappropriate medication levels
• If one medication results in side effects,
  another might be used without side effects
• Other medications are used to minimize side
  effects
• Good clinical judgment by the clinician may help
  to minimize side effects

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Non-stimulant Medications

• 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)

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Psychosocial Treatments

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

NEED FOR MULTIMODAL TREATMENT!
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Educational Interventions

• Special Education Services for existing learning
  problems
• Classroom accommodations
• Classroom behavior modification programs
• 504 Plan

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The Daily Report Card

• Specific set of behaviors relevant to the
  specific child
• Everyday teacher marks how the child did on these
  behaviors
• Child is rewarded (or not) based on performance
  at school
• Integrates the classroom and home

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ADHD TreatmentConclusions

• It is essential to treat the full range of
  difficulties that impact on child and family
  functioning
• Treatment of ADHD needs to be multimodal
• 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